2010 medicare fee schedule

GailPunzalan 151 views 47 slides Aug 25, 2010
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California - MEDICARE CARRIER 01192 FSY2009 LOCALITY 18 FEE SCHEDULE # These amounts apply when service is performed in a facility setting. Limiting charge applies to unassigned claims by non-participating providers. All CPT codes and modifiers are bolded. ANES
G0101
G0102
G0102
G0104
G0104
G0105
G0105
G010553
G010553
G0106
G010626
G0106TC
G0108
G0109
G0117
G0118
G0120
G012026
G0120TC
G0121
G0121
G012153
G012153
G0124
G0127
G0127
G0128
G0130
G013026
G0130TC
G0141
G0166
G0168
G0168
G0179
G0180
G0181
G0182
G0186
G0202
G020226
G0202TC
G0204
G020426
G0204TC
G0206
G020626
G0206TC
G0237
G0238
G0239
G0245
G0245
G0246
G0246
G0247
G0247
G0248
G0249
G0250
G0268
G0268
G0270
G0270
G0271
G0275
G0278
G0281
G0283
G0288
G0289
G0329
G0339
G0340
G0341
G0342
G0343
G0364
G0364
G0365
G036526
G0365TC
G0372
G0372
G0389
G038926
G0389TC
G0392
G0392
G0393
G0393
G0396
G0396
G0397
G0397
G0402
G0403
G0404
G0405
G0406
G0407
G0408
G0409
G0412
G0413
G0414
G0415
G0416
G041626
G0416TC
G0417
G041726
G0417TC
G0418
G041826
G0418TC
G0419
G041926
G0419TC
G9041
G9042
G9043
G9044
M0064
M0064
P3001
Q0035
Q003526
Q0035TC
Q0091
Q0091
Q0092
R0070
0016T
0030T
0067T
0067T26
0067TTC
0073T
0075T
0075T26
0076T
0076T26
0078T
0079T
0080T
0081T
0144T
0144T26
0144TTC
0145T
0145T26
0145TTC
0146T
0146T26
0146TTC
0147T
0147T26
0147TTC
0148T
0148T26
0148TTC
0149T
0149T26
0149TTC
0150T
0150T26
0150TTC
0151T
0151T26
0151TTC
0159T
0159T26
0159TTC
0171T
0172T
0177T
10021
10021
10022
10022
10040
10040
10060
10060
10061
10061
10080
10080
10081
10081
10120
10120
10121
10121
10140
10140
10160
10160
10180
10180
11000
11000
11001
11001
11004
11005
11006
11008
11010
11010
11011
11011
11012
11012
11040
11040
11041
11041
11042
11042
11043
11043
11044
11044
11055
11055
11056
11056
11057






California - MEDICARE CARRIER 01192 FSY2009 LOCALITY 18 FEE SCHEDULE PAGE: 1
PROCEDURE PAR NONPAR LIMITING
CODE/MOD FEE FEE CHARGE
PROCEDURE
CODE/MOD
PAR
FEE
NONPAR
FEE
LIMITING
CHARGE
PROCEDURE
CODE/MOD
PAR
FEE
NONPAR LIMITING
FEE CHARGE
ANES 21.80 20.71 23.82
G0101 39.12 37.16 42.73
G0102 21.69 20.61 23.70
# G0102 9.32 8.85 10.18
G0104 145.72 138.43 159.19
# G0104 64.87 61.63 70.87
G0105 422.93 401.78 462.05
# G0105 225.88 214.59 246.78
G010553 145.72 138.43 159.19
# G0105 53 64.87 61.63 70.87
G0106 233.85 222.16 255.48
G010626 54.68 51.95 59.74
G0106TC 179.17 170.21 195.74
G0108 28.12 26.71 30.72
G0109 15.75 14.96 17.20
G0117 50.32 47.80 54.97
G0118 34.95 33.20 38.18
G0120 233.85 222.16 255.48
G012026 54.68 51.95 59.74
G0120TC 179.17 170.21 195.74
G0121 422.93 401.78 462.05
# G0121 225.88 214.59 246.78
G012153 145.72 138.43 159.19
# G0121 53 64.87 61.63 70.87
G0124 30.05 28.55 32.83
G0127 21.69 20.61 23.70
# G0127 8.88 8.44 9.71
G0128 9.48 9.01 10.36
G0130 37.39 35.52 40.85
G013026 11.20 10.64 12.24
G0130TC 26.19 24.88 28.61
G0141 30.05 28.55 32.83
G0166 183.18 174.02 200.12
G0168 89.34 84.87 97.60
# G0168 27.04 25.69 29.54
G0179 44.43 42.21 48.54
G0180 58.28 55.37 63.68
G0181 110.28 104.77 120.49
G0182 112.93 107.28 123.37
G0186 372.31 353.69 406.74
G0202 152.89 145.25 167.04
G020226 37.76 35.87 41.25
G0202TC 115.13 109.37 125.78
G0204 179.44 170.47 196.04
G020426 46.64 44.31 50.96
G0204TC 132.81 126.17 145.10
G0206 142.44 135.32 155.62
G020626 37.76 35.87 41.25
G0206TC 104.68 99.45 114.37
G0237 12.51 11.88 13.66
G0238 13.39 12.72 14.63
G0239 13.83 13.14 15.11
G0245 70.87 67.33 77.43
# G0245 48.34 45.92 52.81
G0246 41.78 39.69 45.64
# G0246 24.54 23.31 26.81
G0247 46.75 44.41 51.07
# G0247 26.86 25.52 29.35
G0248 181.88 172.79 198.71
G0249 154.48 146.76 168.77
G0250 10.58 10.05 11.56
G0268 52.64 50.01 57.51
# G0268 33.20 31.54 36.27
G0270 25.23 23.97 27.57
# G0270 23.02 21.87 25.15
G0271 14.09 13.39 15.40
G0275 15.42 14.65 16.85
G0278 15.42 14.65 16.85
G0281 12.79 12.15 13.97
G0283 12.79 12.15 13.97
G0288 155.44 147.67 169.82
G0289 92.71 88.07 101.28
G0329 9.17 8.71 10.02
G0339 3,958.14 3,760.23 4,324.26
G0340 2,687.41 2,553.04 2,936.00
G0341 445.20 422.94 486.38
G0342 722.27 686.16 789.08
G0343
G0364
# G0364
C G0365
G036526
C G0365TC
G0372
# G0372
G0389
G038926
G0389TC
G0392
# G0392
G0393
# G0393
G0396
# G0396
G0397
# G0397
G0402
G0403
G0404
G0405
G0406
G0407
G0408
G0409
G0412
G0413
G0414
G0415
G0416
G041626
G0416TC
G0417
G041726
G0417TC
G0418
G041826
G0418TC
G0419
G041926
G0419TC
G9041
G9042
G9043
G9044
M0064
# M0064
P3001
Q0035
Q003526
Q0035TC
Q0091
# Q0091
Q0092
R0070
0016T
0030T
0067T
0067T26
C 0067T TC
0073T
0075T
0075T26
0076T
0076T26
0078T
0079T
0080T
0081T
0144T
0144T26
C 0144T TC
0145T
0145T26
C 0145T TC
1,197.19
14.24
10.26
197.79
13.06
184.73
12.42
8.88
130.56
32.81
97.75
2,570.17
478.18
1,949.18
340.08
33.53
31.76
65.14
63.38
103.14
24.04
16.49
8.88
40.01
71.90
102.90
10.45
746.22
1,088.19
1,031.54
1,403.07
748.45
203.38
545.06
1,455.14
390.20
1,064.94
2,496.01
676.79
1,819.22
2,966.52
783.63
2,182.89
24.76
8.46
8.02
7.58
46.88
17.72
30.05
21.83
8.88
12.95
46.28
19.33
19.73
194.73
372.31
27.02
492.10
68.14
231.61
631.15
1,197.26
914.45
395.09
91.44
1,493.47
144.24
263.34
26.33
325.14
60.96
125.08
482.63
76.21
336.82
1,137.33
13.53
9.75
187.90
12.41
175.49
11.80
8.44
124.03
31.17
92.86
2,441.66
454.27
1,851.72
323.08
31.85
30.17
61.88
60.21
97.98
22.84
15.67
8.44
38.01
68.31
97.76
9.93
708.91
1,033.78
979.96
1,332.92
711.03
193.21
517.81
1,382.38
370.69
1,011.69
2,371.21
642.95
1,728.26
2,818.19
744.45
2,073.75
23.52
8.04
7.62
7.20
44.54
16.83
28.55
20.74
8.44
12.30
43.97
18.36
18.74
184.99
353.69
25.67
467.50
64.73
220.03
599.59
1,137.40
868.73
375.34
86.87
1,418.80
137.03
250.17
25.01
308.88
57.91
118.83
458.50
72.40
319.98
1,307.93
15.56
11.21
216.09
14.27
201.81
13.57
9.71
142.63
35.85
106.79
2,807.91
522.41
2,129.48
371.54
36.63
34.70
71.16
69.24
112.68
26.27
18.02
9.71
43.71
78.56
112.42
11.42
815.25
1,188.85
1,126.95
1,532.86
817.68
222.19
595.48
1,589.74
426.29
1,163.44
2,726.89
739.39
1,987.50
3,240.92
856.12
2,384.81
27.05
9.25
8.76
8.28
51.22
19.35
32.83
23.85
9.71
14.15
50.57
21.11
21.55
212.74
406.74
29.52
537.63
74.44
253.03
689.53
1,308.01
999.04
431.64
99.90
1,631.62
157.58
287.70
28.76
355.21
66.60
136.65
527.28
83.26
367.98
0146T
0146T26
C 0146T TC
0147T
0147T26
C 0147T TC
0148T
0148T26
C 0148T TC
0149T
0149T26
C 0149T TC
0150T
0150T26
C 0150T TC
0151T
0151T26
C 0151T TC
0159T
0159T26
0159T TC
0171T
0172T
0177T
10021
# 10021
10022
# 10022
10040
# 10040
10060
# 10060
10061
# 10061
10080
# 10080
10081
# 10081
10120
# 10120
10121
# 10121
10140
# 10140
10160
# 10160
10180
# 10180
11000
# 11000
11001
# 11001
11004
11005
11006
11008
11010
# 11010
11011
# 11011
11012
# 11012
11040
# 11040
11041
# 11041
11042
# 11042
11043
# 11043
11044
# 11044
11055
# 11055
11056
# 11056
11057
640.11
101.61
336.82
640.11
101.61
336.82
640.11
101.61
336.82
640.11
101.61
336.82
640.11
101.61
336.82
203.21
60.96
125.08
19.67
3.27
16.41
824.24
412.12
1,363.16
145.57
69.58
149.85
69.00
101.80
88.10
110.45
94.11
186.32
164.67
168.93
96.47
260.52
165.09
137.14
91.63
264.19
185.54
156.49
120.26
127.62
97.14
235.43
177.55
54.60
32.51
22.59
16.40
582.20
758.21
720.71
274.34
479.10
286.47
531.67
304.57
724.99
443.56
47.91
28.02
55.91
35.15
75.78
47.06
275.40
237.85
376.64
328.04
49.85
23.34
60.28
32.89
72.32
608.10 699.32
96.53 111.01
319.98 367.98
608.10 699.32
96.53 111.01
319.98 367.98
608.10 699.32
96.53 111.01
319.98 367.98
608.10 699.32
96.53 111.01
319.98 367.98
608.10 699.32
96.53 111.01
319.98 367.98
193.05 222.01
57.91 66.60
118.83 136.65
18.69 21.49
3.11 3.58
15.59 17.93
783.03 900.48
391.51 450.24
1,295.00 1,489.25
138.29 159.03
66.10 76.02
142.36 163.71
65.55 75.38
96.71 111.22
83.70 96.26
104.93 120.67
89.40 102.81
177.00 203.55
156.44 179.91
160.48 184.55
91.65 105.40
247.49 284.61
156.84 180.37
130.28 149.82
87.05 100.11
250.98 288.63
176.26 202.70
148.67 170.97
114.25 131.39
121.24 139.43
92.28 106.12
223.66 257.21
168.67 193.97
51.87 59.65
30.88 35.51
21.46 24.68
15.58 17.92
553.09 636.05
720.30 828.35
684.67 787.37
260.62 299.71
455.15 523.42
272.15 312.97
505.09 580.85
289.34 332.74
688.74 792.05
421.38 484.59
45.51 52.34
26.62 30.61
53.11 61.08
33.39 38.40
71.99 82.79
44.71 51.42
261.63 300.87
225.96 259.85
357.81 411.48
311.64 358.39
47.36 54.46
22.17 25.50
57.27 65.86
31.25 35.94
68.70 79.01
CODES: ANES - 11057
# - These amounts apply when the service is performed in a facility setting.
C - The payment for the technical component is capped at the OPPS amount.
Limiting charge applies to unassigned claims by non-participating providers. All CPT codes and modifiers are bolded.
All Current Procedural Terminology (CPT) codes and descriptors are copyrighted 2008 by the American Medical Association.

11057
11100
11100
11101
11101
11200
11200
11201
11201
11300
11300
11301
11301
11302
11302
11303
11303
11305
11305
11306
11306
11307
11307
11308
11308
11310
11310
11311
11311
11312
11312
11313
11313
11400
11400
11401
11401
11402
11402
11403
11403
11404
11404
11406
11406
11420
11420
11421
11421
11422
11422
11423
11423
11424
11424
11426
11426
11440
11440
11441
11441
11442
11442
11443
11443
11444
11444
11446
11446
11450
11450
11451
11451
11462
11462
11463
11463
11470
11470
11471
11471
11600
11600
11601
11601
11602
11602
11603
11603
11604
11604
11606
11606
11620
11620
11621
11621
11622
11622
11623
11623
11624
11624
11626
11626
11640
11640
11641
11641
11642
11642
11643
11643
11644
11644
11646
11646
11719
11719
11720
11720
11721
11721
11730
11730
11732
11732
11740
11740
11750
11750
11752
11752
11755
11755
11760
11760
11762
11762
11765
11765
11770
11770
11771
11771
11772
11772
11900
11900
11901
11901
11920
11920
11921
11921
11922
11922
11950
11950
11951
11951
11952
11952
11954
11954
11960
11970
11971
11971
11976
11976
11980
11980
11981
11981
11982
11982
11983
11983
12001
12001
12002
12002
12004
12004
12005
12005
12006
12006
12007
12007
12011
12011
12013
12013
12014
12014
12015
12015
12016
12016
12017
12018
12020
12020
12021
12021
12031
12031
12032
12032
12034
12034
12035
12035
12036
12036
12037
12037
12041
12041
12042
12042
12044
12044
12045
12045
12046
12046
12047
12047






California - MEDICARE CARRIER 01192 FSY2009 LOCALITY 18 FEE SCHEDULE PAGE: 2
PROCEDURE PAR NONPAR CHARGE
CODE/MOD FEE FEE LIMIT
PROCEDURE PAR NONPAR CHARGE
CODE/MOD FEE FEE LIMIT
PROCEDURE PAR NONPAR CHARGE
CODE/MOD FEE FEE LIMIT
# 11057 42.72 40.58 46.67
11100 106.83 101.49 116.71
11470 385.39 366.12 421.04
# 11470 262.56 249.43 286.84
# 11921 137.42 130.55 150.13
11922 62.84 59.70 68.66
# 11100 48.95 46.50 53.48 11471 482.82 458.68 527.48 # 11922 30.59 29.06 33.42
11101 33.65 31.97 36.77
# 11101 25.25 23.99 27.59
# 11471 328.63 312.20 359.03
11600 181.07 172.02 197.82
11950 76.58 72.75 83.66
# 11950 50.95 48.40 55.66
11200 82.95 78.80 90.62
# 11200 69.26 65.80 75.67
# 11600 111.26 105.70 121.56
11601 223.35 212.18 244.01
11951 101.77 96.68 111.18
# 11951 70.84 67.30 77.40
11201 18.54 17.61 20.25 # 11601 144.27 137.06 157.62 11952 143.20 136.04 156.45
# 11201 16.77 15.93 18.32
11300 69.94 66.44 76.41
11602 245.44 233.17 268.15
# 11602 158.85 150.91 173.55
# 11952 102.55 97.42 112.03
11954 164.19 155.98 179.38
# 11300 29.74 28.25 32.49
11301 94.93 90.18 103.71
11603 276.97 263.12 302.59
# 11603 187.73 178.34 205.09
# 11954 115.59 109.81 126.28
11960 922.34 876.22 1,007.65
# 11301 50.75 48.21 55.44
11302 113.33 107.66 123.81
11604 305.41 290.14 333.66
# 11604 205.56 195.28 224.57
11970 600.36 570.34 655.89
11971 469.56 446.08 512.99
# 11302 62.96 59.81 68.78 11606 425.46 404.19 464.82 # 11971 302.99 287.84 331.02
11303 132.97 126.32 145.27
# 11303 73.77 70.08 80.59
# 11606 301.75 286.66 329.66
11620 185.13 175.87 202.25
11976 152.01 144.41 166.07
# 11976 97.22 92.36 106.21
11305 70.92 67.37 77.48
# 11305 37.35 35.48 40.80
# 11620 113.12 107.46 123.58
11621 225.50 214.23 246.36
11980 106.17 100.86 115.99
# 11980 81.87 77.78 89.45
11306 97.52 92.64 106.54 # 11621 145.97 138.67 159.47 11981 140.78 133.74 153.80
# 11306 56.87 54.03 62.13
11307 115.52 109.74 126.20
11622 254.81 242.07 278.38
# 11622 168.22 159.81 183.78
# 11981 86.88 82.54 94.92
11982 161.45 153.38 176.39
# 11307 67.36 63.99 73.59
11308 128.72 122.28 140.62
11623 295.21 280.45 322.52
# 11623 205.96 195.66 225.01
# 11982 106.22 100.91 116.05
11983 245.88 233.59 268.63
# 11308 80.57 76.54 88.02
11310 86.45 82.13 94.45
11624 330.96 314.41 361.57
# 11624 233.32 221.65 254.90
# 11983 194.19 184.48 212.15
12001 147.13 139.77 160.74
# 11310 43.15 40.99 47.14 11626 401.19 381.13 438.30 # 12001 101.62 96.54 111.02
11311 108.91 103.46 118.98
# 11311 63.41 60.24 69.28
# 11626 291.18 276.62 318.11
11640 193.91 184.21 211.84
12002 156.37 148.55 170.83
# 12002 113.07 107.42 123.53
11312 125.88 119.59 137.53
# 11312 72.86 69.22 79.60
# 11640 119.68 113.70 130.76
11641 237.55 225.67 259.52
12004 184.17 174.96 201.20
# 12004 132.47 125.85 144.73
11313 156.50 148.68 170.98 # 11641 156.25 148.44 170.71 12005 229.06 217.61 250.25
# 11313 97.30 92.44 106.31
11400 118.79 112.85 129.78
11642 272.98 259.33 298.23
# 11642 183.74 174.55 200.73
# 12005 164.56 156.33 179.78
12006 283.51 269.33 309.73
# 11400 75.49 71.72 82.48
11401 144.82 137.58 158.22
11643 318.30 302.39 347.75
# 11643 228.17 216.76 249.27
# 12006 207.52 197.14 226.71
12007 321.42 305.35 351.15
# 11401 99.76 94.77 108.99
11402 161.35 153.28 176.27
11644 391.82 372.23 428.06
# 11644 283.58 269.40 309.81
# 12007 237.92 226.02 259.92
12011 156.74 148.90 171.24
# 11402 110.10 104.60 120.29 11646 511.96 486.36 559.31 # 12011 105.05 99.80 114.77
11403 184.22 175.01 201.26
# 11403 140.04 133.04 153.00
# 11646 397.53 377.65 434.30
11719 21.98 20.88 24.01
12013 172.58 163.95 188.54
# 12013 120.01 114.01 131.11
11404 209.66 199.18 229.06
# 11404 155.32 147.55 169.68
# 11719 9.17 8.71 10.02
11720 31.73 30.14 34.66
12014 202.72 192.58 221.47
# 12014 143.96 136.76 157.27
11406 291.55 276.97 318.52 # 11720 17.15 16.29 18.73 12015 253.96 241.26 277.45
# 11406 229.25 217.79 250.46
11420 119.24 113.28 130.27
11721 44.84 42.60 48.99
# 11721 29.37 27.90 32.09
# 12015 179.74 170.75 196.36
12016 302.69 287.56 330.69
# 11420 81.24 77.18 88.76
11421 153.71 146.02 167.92
11730 99.70 94.72 108.93
# 11730 59.50 56.53 65.01
# 12016 219.19 208.23 239.46
12017 260.65 247.62 284.76
# 11421 109.09 103.64 119.19
11422 171.30 162.74 187.15
11732 45.96 43.66 50.21
# 11732 30.94 29.39 33.80
12018 325.08 308.83 355.15
12020 270.41 256.89 295.42
# 11422 132.42 125.80 144.67 11740 46.42 44.10 50.72 # 12020 187.35 177.98 204.68
11423 198.66 188.73 217.04
# 11423 153.59 145.91 167.80
# 11740 32.72 31.08 35.74
11750 215.78 204.99 235.74
12021 158.09 150.19 172.72
# 12021 136.44 129.62 149.06
11424 228.25 216.84 249.37
# 11424 176.11 167.30 192.40
# 11750 176.90 168.06 193.27
11752 306.49 291.17 334.85
12031 240.60 228.57 262.86
# 12031 157.54 149.66 172.11
11426 323.05 306.90 352.94 # 11752 265.40 252.13 289.95 12032 312.41 296.79 341.31
# 11426 266.50 253.18 291.16
11440 131.19 124.63 143.32
11755 135.86 129.07 148.43
# 11755 86.82 82.48 94.85
# 12032 195.33 185.56 213.39
12034 304.08 288.88 332.21
# 11440 98.94 93.99 108.09
11441 164.80 156.56 180.04
11760 206.66 196.33 225.78
# 11760 133.32 126.65 145.65
# 12034 201.14 191.08 219.74
12035 371.98 353.38 406.39
# 11441 128.57 122.14 140.46
11442 185.28 176.02 202.42
11762 271.68 258.10 296.82
# 11762 201.43 191.36 220.06
# 12035 235.90 224.11 257.73
12036 405.64 385.36 443.16
# 11442 142.87 135.73 156.09 11765 134.13 127.42 146.53 # 12036 271.33 257.76 296.42
11443 220.79 209.75 241.21
# 11443 175.29 166.53 191.51
# 11765 69.62 66.14 76.06
11770 260.74 247.70 284.86
12037 456.85 434.01 499.11
# 12037 316.35 300.53 345.61
11444 276.68 262.85 302.28
# 11444 223.22 212.06 243.87
# 11770 175.91 167.11 192.18
11771 530.51 503.98 579.58
12041 251.20 238.64 274.44
# 12041 168.14 159.73 183.69
11446 373.28 354.62 407.81 # 11771 408.57 388.14 446.36 12042 293.23 278.57 320.36
# 11446 313.63 297.95 342.64
11450 352.64 335.01 385.26
11772 644.09 611.89 703.67
# 11772 538.05 511.15 587.82
# 12042 196.92 187.07 215.13
12044 338.54 321.61 369.85
# 11450 231.14 219.58 252.52
11451 459.24 436.28 501.72
11900 57.66 54.78 63.00
# 11900 31.15 29.59 34.03
# 12044 210.42 199.90 229.89
12045 373.81 355.12 408.39
# 11451 303.72 288.53 331.81
11462 349.54 332.06 381.87
11901 72.00 68.40 78.66
# 11901 48.58 46.15 53.07
# 12045 244.36 232.14 266.96
12046 443.34 421.17 484.35
# 11462 223.18 212.02 243.82 11920 186.26 176.95 203.49 # 12046 288.26 273.85 314.93
11463 473.23 449.57 517.01
# 11463 310.64 295.11 339.38
# 11920 116.89 111.05 127.71
11921 211.65 201.07 231.23
12047 474.98 451.23 518.91
# 12047 315.49 299.72 344.68
CODES: 11057 - 12047
# - These amounts apply when the service is performed in a facility setting.
C - The payment for the technical component is capped at the OPPS amount.
Limiting charge applies to unassigned claims by non-participating providers. All CPT codes and modifiers are bolded.
All Current Procedural Terminology (CPT) codes and descriptors are copyrighted 2008 by the American Medical Association..

12051
12051
12052
12052
12053
12053
12054
12054
12055
12055
12056
12056
12057
12057
13100
13100
13101
13101
13102
13102
13120
13120
13121
13121
13122
13122
13131
13131
13132
13132
13133
13133
13150
13150
13151
13151
13152
13152
13153
13153
13160
14000
14000
14001
14001
14020
14020
14021
14021
14040
14040
14041
14041
14060
14060
14061
14061
14300
14300
14350
15002
15002
15003
15003
15004
15004
15005
15005
15040
15040
15050
15050
15100
15100
15101
15101
15110
15110
15111
15111
15115
15115
15116
15116
15120
15120
15121
15121
15130
15130
15131
15131
15135
15135
15136
15136
15150
15150
15151
15151
15152
15152
15155
15155
15156
15156
15157
15157
15170
15170
15171
15171
15175
15175
15176
15176
15200
15200
15201
15201
15220
15220
15221
15221
15240
15240
15241
15241
15260
15260
15261
15261
15300
15300
15301
15301
15320
15320
15321
15321
15330
15330
15331
15331
15335
15335
15336
15336
15340
15340
15341
15341
15360
15360
15361
15361
15365
15365
15366
15366
15400
15400
15401
15401
15420
15420
15421
15421
15430
15430
15570
15570
15572
15572
15574
15574
15576
15576
15600
15600
15610
15610
15620
15620
15630
15630
15650
15650
15731
15731
15732
15732
15734
15734
15736
15736
15738
15738
15740
15740
15750
15756
15757
15758
15760
15760
15770
15775
15775
15776
15776
15780
15780
15781
15781
15782
15782
15783
15783
15786
15786
15787
15787
15788
15788
15789
15789
15792
15792
15793
15793






California - MEDICARE CARRIER 01192 FSY2009 LOCALITY 18 FEE SCHEDULE PAGE: 3
PROCEDURE PAR NONPAR LIMITING
CODE/MOD FEE FEE CHARGE
PROCEDURE
CODE/MOD
PAR
FEE
NONPAR
FEE
LIMITING
CHARGE
PROCEDURE
CODE/MOD
PAR
FEE
NONPAR LIMITING
FEE CHARGE
12051 270.71 257.17 295.75
# 12051 180.58 171.55 197.28
12052 307.04 291.69 335.44
# 12052 212.93 202.28 232.62
12053 337.08 320.23 368.26
# 12053 213.81 203.12 233.59
12054 355.47 337.70 388.36
# 12054 226.02 214.72 246.93
12055 426.28 404.97 465.72
# 12055 273.86 260.17 299.20
12056 503.17 478.01 549.71
# 12056 335.72 318.93 366.77
12057 561.58 533.50 613.53
# 12057 384.86 365.62 420.46
13100 319.83 303.84 349.42
# 13100 236.77 224.93 258.67
13101 404.28 384.07 441.68
# 13101 286.75 272.41 313.27
13102 108.20 102.79 118.21
# 13102 75.07 71.32 82.02
13120 331.89 315.30 362.60
# 13120 247.06 234.71 269.92
13121 447.52 425.14 488.91
# 13121 326.02 309.72 356.18
13122 120.71 114.67 131.87
# 13122 85.81 81.52 93.75
13131 365.38 347.11 399.18
# 13131 278.34 264.42 304.08
13132 582.17 553.06 636.02
# 13132 468.62 445.19 511.97
13133 169.62 161.14 185.31
# 13133 133.83 127.14 146.21
13150 363.59 345.41 397.22
# 13150 276.55 262.72 302.13
13151 413.70 393.02 451.97
# 13151 321.80 305.71 351.57
13152 568.63 540.20 621.23
# 13152 430.34 408.82 470.14
13153 186.45 177.13 203.70
# 13153 144.92 137.67 158.32
13160 806.86 766.52 881.50
14000 621.96 590.86 679.49
# 14000 503.12 477.96 549.65
14001 804.52 764.29 878.93
# 14001 664.91 631.66 726.41
14020 700.08 665.08 764.84
# 14020 576.38 547.56 629.69
14021 882.38 838.26 964.00
# 14021 741.44 704.37 810.03
14040 773.14 734.48 844.65
# 14040 652.08 619.48 712.40
14041 961.06 913.01 1,049.96
# 14041 803.77 763.58 878.12
14060 782.63 743.50 855.03
# 14060 687.20 652.84 750.77
14061 1,030.71 979.17 1,126.05
# 14061 857.96 815.06 937.32
14300 1,106.73 1,051.39 1,209.10
# 14300 954.75 907.01 1,043.06
14350 751.28 713.72 820.78
15002 335.93 319.13 367.00
# 15002 227.68 216.30 248.75
15003 72.99 69.34 79.74
# 15003 45.60 43.32 49.82
15004 406.43 386.11 444.03
# 15004 284.48 270.26 310.80
15005 120.80 114.76 131.97
# 15005 90.31 85.79 98.66
15040 260.99 247.94 285.13
# 15040 128.44 122.02 140.32
15050 545.09 517.84 595.52
# 15050 441.26 419.20 482.08
15100 867.16 823.80 947.37
# 15100 715.17 679.41 781.32
15101 193.92 184.22 211.85
# 15101 113.51 107.83 124.00
15110 846.77 804.43 925.09
# 15110
15111
# 15111
15115
# 15115
15116
# 15116
15120
# 15120
15121
# 15121
15130
# 15130
15131
# 15131
15135
# 15135
15136
# 15136
15150
# 15150
15151
# 15151
15152
# 15152
15155
# 15155
15156
# 15156
15157
# 15157
15170
# 15170
15171
# 15171
15175
# 15175
15176
# 15176
15200
# 15200
15201
# 15201
15220
# 15220
15221
# 15221
15240
# 15240
15241
# 15241
15260
# 15260
15261
# 15261
15300
# 15300
15301
# 15301
15320
# 15320
15321
# 15321
15330
# 15330
15331
# 15331
15335
# 15335
15336
# 15336
15340
# 15340
15341
# 15341
15360
# 15360
729.68
121.62
107.93
855.97
756.57
165.29
149.38
939.53
782.24
271.95
173.42
675.70
560.82
99.08
88.47
861.04
765.16
90.39
83.32
695.48
634.51
127.83
116.79
167.19
154.82
730.30
679.49
177.75
167.59
196.40
181.82
422.43
360.58
93.31
88.45
534.51
476.19
149.44
140.16
806.13
654.59
151.39
80.25
771.73
623.28
141.22
73.62
922.04
796.56
186.96
114.94
997.27
860.75
217.50
145.48
340.34
287.76
63.25
57.95
382.86
324.98
94.22
87.15
316.88
262.98
63.25
58.39
331.59
279.01
87.77
79.81
318.74
271.02
47.91
27.58
363.70
307.59
693.20
115.54
102.53
813.17
718.74
157.03
141.91
892.55
743.13
258.35
164.75
641.92
532.78
94.13
84.05
817.99
726.90
85.87
79.15
660.71
602.78
121.44
110.95
158.83
147.08
693.79
645.52
168.86
159.21
186.58
172.73
401.31
342.55
88.64
84.03
507.78
452.38
141.97
133.15
765.82
621.86
143.82
76.24
733.14
592.12
134.16
69.94
875.94
756.73
177.61
109.19
947.41
817.71
206.63
138.21
323.32
273.37
60.09
55.05
363.72
308.73
89.51
82.79
301.04
249.83
60.09
55.47
315.01
265.06
83.38
75.82
302.80
257.47
45.51
26.20
345.52
292.21
797.18
132.87
117.91
935.15
826.55
180.58
163.20
1,026.43
854.60
297.10
189.46
738.21
612.70
108.25
96.66
940.69
835.94
98.75
91.02
759.82
693.20
139.66
127.59
182.65
169.14
797.86
742.35
194.19
183.09
214.57
198.64
461.51
393.93
101.94
96.63
583.95
520.24
163.27
153.12
880.69
715.14
165.39
87.68
843.11
680.94
154.28
80.43
1,007.33
870.24
204.25
125.57
1,089.52
940.37
237.62
158.94
371.82
314.38
69.10
63.31
418.28
355.04
102.94
95.21
346.20
287.30
69.10
63.79
362.26
304.82
95.89
87.19
348.22
296.09
52.34
30.13
397.35
336.04
15361
# 15361
15365
# 15365
15366
# 15366
15400
# 15400
15401
# 15401
15420
# 15420
15421
# 15421
15430
# 15430
15570
# 15570
15572
# 15572
15574
# 15574
15576
# 15576
15600
# 15600
15610
# 15610
15620
# 15620
15630
# 15630
15650
# 15650
15731
# 15731
15732
# 15732
15734
# 15734
15736
# 15736
15738
# 15738
15740
# 15740
15750
15756
15757
15758
15760
# 15760
15770
15775
# 15775
15776
# 15776
15780
# 15780
15781
# 15781
15782
# 15782
15783
# 15783
15786
# 15786
15787
# 15787
15788
# 15788
15789
# 15789
15792
# 15792
15793
# 15793
70.65
63.58
355.20
304.83
86.76
79.25
397.22
355.69
95.51
57.51
448.30
394.40
115.43
85.82
526.75
506.43
884.84
712.98
856.88
723.45
903.84
764.23
804.24
671.26
338.62
205.63
336.67
242.12
444.29
318.37
468.76
348.14
521.29
390.95
1,132.34
1,016.58
1,491.29
1,312.80
1,536.75
1,350.30
1,364.91
1,166.09
1,450.21
1,266.86
1,020.84
866.21
913.67
2,382.44
2,354.86
2,358.43
846.69
707.96
657.33
325.97
233.63
451.18
334.54
841.35
650.04
543.68
433.23
581.35
418.76
495.87
374.81
243.63
137.59
50.66
18.85
444.83
243.36
579.39
431.82
438.99
270.65
483.83
360.12
67.12 77.19
60.40 69.46
337.44 388.06
289.59 333.03
82.42 94.78
75.29 86.58
377.36 433.96
337.91 388.60
90.73 104.34
54.63 62.82
425.89 489.77
374.68 430.88
109.66 126.11
81.53 93.76
500.41 575.47
481.11 553.28
840.60 966.69
677.33 778.93
814.04 936.15
687.28 790.37
858.65 987.45
726.02 834.92
764.03 878.63
637.70 733.36
321.69 369.94
195.35 224.65
319.84 367.82
230.01 264.51
422.08 485.39
302.45 347.82
445.32 512.12
330.73 380.34
495.23 569.51
371.40 427.11
1,075.72 1,237.08
965.75 1,110.61
1,416.73 1,629.24
1,247.16 1,434.23
1,459.91 1,678.90
1,282.79 1,475.21
1,296.66 1,491.16
1,107.79 1,273.96
1,377.70 1,584.36
1,203.52 1,384.05
969.80 1,115.27
822.90 946.34
867.99 998.19
2,263.32 2,602.82
2,237.12 2,572.69
2,240.51 2,576.59
804.36 925.01
672.56 773.44
624.46 718.13
309.67 356.12
221.95 255.24
428.62 492.91
317.81 365.48
799.28 919.17
617.54 710.17
516.50 593.98
411.57 473.31
552.28 635.12
397.82 457.49
471.08 541.74
356.07 409.48
231.45 266.17
130.71 150.32
48.13 55.35
17.91 20.60
422.59 485.98
231.19 265.87
550.42 632.98
410.23 471.76
417.04 479.60
257.12 295.69
459.64 528.59
342.11 393.43
CODES: 12051 - 15793
# - These amounts apply when the service is performed in a facility setting.
C - The payment for the technical component is capped at the OPPS amount.
Limiting charge applies to unassigned claims by non-participating providers. All CPT codes and modifiers are bolded.
All Current Procedural Terminology (CPT) codes and descriptors are copyrighted 2008 by the American Medical Association.

15819
15820
15820
15821
15821
15822
15822
15823
15823
15830
15832
15833
15834
15835
15836
15837
15837
15838
15839
15839
15840
15841
15842
15845
15851
15851
15852
15860
15920
15922
15931
15933
15934
15935
15936
15937
15940
15941
15944
15945
15946
15950
15951
15952
15953
15956
15958
16000
16000
16020
16020
16025
16025
16030
16030
16035
16036
17000
17000
17003
17003
17004
17004
17106
17106
17107
17107
17108
17108
17110
17110
17111
17111
17250
17250
17260
17260
17261
17261
17262
17262
17263
17263
17264
17264
17266
17266
17270
17270
17271
17271
17272
17272
17273
17273
17274
17274
17276
17276
17280
17280
17281
17281
17282
17282
17283
17283
17284
17284
17286
17286
17311
17311
17312
17312
17313
17313
17314
17314
17315
17315
17340
17340
17360
17360
19000
19000
19001
19001
19020
19020
19030
19030
19100
19100
19101
19101
19102
19102
19103
19103
19105
19105
19110
19110
19112
19112
19120
19120
19125
19125
19126
19260
19271
19272
19290
19290
19291
19291
19295
19296
19296
19297
19298
19298
19300
19300
19301
19302
19303
19304
19305
19306
19307
19316
19318
19324
19325
19328
19330
19340
19342
19350
19350
19355
19355
19357
19361
19364
19366
19367
19368
19369
19370
19371
19380
19396
19396
20000
20000
20005
20005
20100
20101
20101
20102
20102
20103
20103
20150
20200
20200
20205
20205
20206
20206
20220
20220
20225
20225
20240
20245
20250
20251
20500
20500
20501
20501
20520
20520
20525






California - MEDICARE CARRIER 01192 FSY2009 LOCALITY 18 FEE SCHEDULE PAGE: 4
PROCEDURE PAR NONPAR CHARGE
CODE/MOD FEE FEE LIMIT
PROCEDURE PAR NONPAR CHARGE
CODE/MOD FEE FEE LIMIT
PROCEDURE PAR NONPAR CHARGE
CODE/MOD FEE FEE LIMIT
15819 734.61 697.88 802.56
15820 534.94 508.19 584.42
17261 145.54 138.26 159.00
# 17261 91.64 87.06 100.12
19272 1,803.97 1,713.77 1,970.84
19290 177.40 168.53 193.81
# 15820 480.16 456.15 524.57 17262 176.24 167.43 192.54 # 19290 70.48 66.96 77.00
15821 567.51 539.13 620.00
# 15821 507.42 482.05 554.36
# 17262 116.60 110.77 127.39
17263 194.14 184.43 212.09
19291 76.06 72.26 83.10
# 19291 34.98 33.23 38.21
15822 420.85 399.81 459.78
# 15822 368.71 350.27 402.81
# 17263 128.75 122.31 140.66
17264 207.57 197.19 226.77
19295 104.12 98.91 113.75
# 19296 205.05 194.80 224.02
15823 657.80 624.91 718.65 # 17264 137.32 130.45 150.02 19296 4,321.45 4,105.38 4,721.19
# 15823 600.80 570.76 656.37
15830 1,167.04 1,108.69 1,274.99
17266 234.81 223.07 256.53
# 17266 159.26 151.30 174.00
19297 92.04 87.44 100.56
19298 1,435.06 1,363.31 1,567.81
15832 888.47 844.05 970.66
15833 839.92 797.92 917.61
17270 150.29 142.78 164.20
# 17270 98.59 93.66 107.71
# 19298 338.03 321.13 369.30
19300 498.45 473.53 544.56
15834 833.65 791.97 910.77
15835 880.50 836.48 961.95
17271 165.79 157.50 181.13
# 17271 111.01 105.46 121.28
# 19300 380.92 361.87 416.15
19301 594.09 564.39 649.05
15836 735.88 699.09 803.95 17272 189.41 179.94 206.93 19302 853.88 811.19 932.87
15837 772.16 733.55 843.58
# 15837 666.57 633.24 728.23
# 17272 128.44 122.02 140.32
17273 210.82 200.28 230.32
19303 917.24 871.38 1,002.09
19304 541.20 514.14 591.26
15838 574.74 546.00 627.90
15839 854.50 811.78 933.55
# 17273 144.54 137.31 157.91
17274 248.46 236.04 271.45
19305 1,065.60 1,012.32 1,164.17
19306 1,118.41 1,062.49 1,221.86
# 15839 720.63 684.60 787.29 # 17274 176.89 168.05 193.26 19307 1,124.94 1,068.69 1,228.99
15840 1,009.08 958.63 1,102.42
15841 1,680.44 1,596.42 1,835.88
17276 286.36 272.04 312.85
# 17276 212.13 201.52 231.75
19316 774.82 736.08 846.49
19318 1,142.68 1,085.55 1,248.38
15842 2,652.75 2,520.11 2,898.13
15845 945.17 897.91 1,032.60
17280 141.56 134.48 154.65
# 17280 89.87 85.38 98.19
19324 473.29 449.63 517.07
19325 646.52 614.19 706.32
15851 95.44 90.67 104.27
# 15851 45.52 43.24 49.73
17281 179.14 170.18 195.71
# 17281 124.79 118.55 136.33
19328 488.36 463.94 533.53
19330 626.35 595.03 684.28
15852 47.71 45.32 52.12 17282 207.35 196.98 226.53 19340 400.13 380.12 437.14
15860 112.85 107.21 123.29
15920 584.01 554.81 638.03
# 17282 144.61 137.38 157.99
17283 249.30 236.84 272.37
19342 920.53 874.50 1,005.68
19350 858.23 815.32 937.62
15922 742.93 705.78 811.65
15931 659.82 626.83 720.85
# 17283 180.38 171.36 197.06
17284 288.95 274.50 315.68
# 19350 679.30 645.34 742.14
19355 705.87 670.58 771.17
15933 817.59 776.71 893.22 # 17284 214.73 203.99 234.59 # 19355 554.77 527.03 606.08
15934 906.65 861.32 990.52
15935 1,083.25 1,029.09 1,183.45
17286 362.84 344.70 396.41
# 17286 287.73 273.34 314.34
19357 1,548.56 1,471.13 1,691.80
19361 1,655.61 1,572.83 1,808.75
15936 879.79 835.80 961.17
15937 1,030.56 979.03 1,125.88
17311 710.27 674.76 775.97
# 17311 383.77 364.58 419.27
19364 2,804.95 2,664.70 3,064.41
19366 1,378.18 1,309.27 1,505.66
15940 679.57 645.59 742.43
15941 889.86 845.37 972.18
17312 428.55 407.12 468.19
# 17312 204.10 193.90 222.99
19367 1,820.62 1,729.59 1,989.03
19368 2,251.39 2,138.82 2,459.64
15944 874.79 831.05 955.71 17313 648.99 616.54 709.02 19369 2,049.61 1,947.13 2,239.20
15945 972.26 923.65 1,062.20
15946 1,617.30 1,536.44 1,766.91
# 17313 344.58 327.35 376.45
17314 397.15 377.29 433.88
19370 679.79 645.80 742.67
19371 783.70 744.52 856.20
15950 566.61 538.28 619.02
15951 806.94 766.59 881.58
# 17314 189.50 180.03 207.03
17315 83.90 79.71 91.67
19380 766.62 728.29 837.53
19396 223.60 212.42 244.28
15952 847.25 804.89 925.62 # 17315 53.86 51.17 58.85 # 19396 133.47 126.80 145.82
15953 944.61 897.38 1,031.99
15956 1,133.49 1,076.82 1,238.34
17340 48.10 45.70 52.56
# 17340 46.33 44.01 50.61
20000 208.21 197.80 227.47
# 20000 157.40 149.53 171.96
15958 1,159.65 1,101.67 1,266.92
16000 68.87 65.43 75.24
17360 133.56 126.88 145.91
# 17360 100.43 95.41 109.72
20005 306.56 291.23 334.91
# 20005 239.41 227.44 261.56
# 16000 46.34 44.02 50.62
16020 82.72 78.58 90.37
19000 119.13 113.17 130.15
# 19000 47.11 44.75 51.46
20100 585.52 556.24 639.68
20101 405.37 385.10 442.87
# 16020 57.10 54.25 62.39 19001 28.42 27.00 31.05 # 20101 202.58 192.45 221.32
16025 146.98 139.63 160.57
# 16025 115.17 109.41 125.82
# 19001 23.56 22.38 25.74
19020 441.09 419.04 481.90
20102 473.11 449.45 516.87
# 20102 246.90 234.56 269.74
16030 176.95 168.10 193.32
# 16030 131.00 124.45 143.12
# 19020 284.25 270.04 310.55
19030 181.11 172.05 197.86
20103 572.80 544.16 625.78
# 20103 354.10 336.40 386.86
16035 213.85 203.16 233.63 # 19030 85.24 80.98 93.13 20150 966.07 917.77 1,055.44
16036 85.09 80.84 92.97
17000 81.14 77.08 88.64
19100 143.78 136.59 157.08
# 19100 68.67 65.24 75.03
20200 197.56 187.68 215.83
# 20200 93.74 89.05 102.41
# 17000 55.08 52.33 60.18
17003 7.78 7.39 8.50
19101 325.41 309.14 355.51
# 19101 212.75 202.11 232.43
20205 267.02 253.67 291.72
# 20205 149.05 141.60 162.84
# 17003 4.69 4.46 5.13
17004 178.44 169.52 194.95
19102 237.32 225.45 259.27
# 19102 111.40 105.83 121.70
20206 283.08 268.93 309.27
# 20206 66.15 62.84 72.27
# 17004 136.47 129.65 149.10 19103 607.61 577.23 663.81 20220 190.50 180.98 208.13
17106 350.25 332.74 382.65
# 17106 283.09 268.94 309.28
# 19103 204.24 194.03 223.13
19105 2,410.22 2,289.71 2,633.17
# 20220 82.25 78.14 89.86
20225 742.85 705.71 811.57
17107 464.81 441.57 507.81
# 17107 375.13 356.37 409.83
# 19105 204.68 194.45 223.62
19110 453.78 431.09 495.75
# 20225 125.19 118.93 136.77
20240 231.54 219.96 252.95
17108 591.04 561.49 645.71 # 19110 319.91 303.91 349.50 20245 632.79 601.15 691.32
# 17108 487.22 462.86 532.29
17110 114.08 108.38 124.64
19112 427.07 405.72 466.58
# 19112 288.78 274.34 315.49
20250 381.48 362.41 416.77
20251 423.26 402.10 462.42
# 17110 69.46 65.99 75.89
17111 134.38 127.66 146.81
19120 460.02 437.02 502.57
# 19120 388.44 369.02 424.37
20500 120.22 114.21 131.34
# 20500 97.24 92.38 106.24
# 17111 85.78 81.49 93.71
17250 77.06 73.21 84.19
19125 508.32 482.90 555.34
# 19125 430.12 408.61 469.90
20501 140.59 133.56 153.59
# 20501 42.51 40.38 46.44
# 17250 36.86 35.02 40.27 19126 158.58 150.65 173.25 20520 193.82 184.13 211.75
17260 96.61 91.78 105.55
# 17260 67.45 64.08 73.69
19260 1,190.29 1,130.78 1,300.40
19271 1,632.19 1,550.58 1,783.17
# 20520 143.90 136.71 157.22
20525 481.03 456.98 525.53
CODES: 15819 - 20525
# - These amounts apply when the service is performed in a facility setting.
C - The payment for the technical component is capped at the OPPS amount.
Limiting charge applies to unassigned claims by non-participating providers. All CPT codes and modifiers are bolded.
All Current Procedural Terminology (CPT) codes and descriptors are copyrighted 2008 by the American Medical Association..

20525
20526
20526
20550
20550
20551
20551
20552
20552
20553
20553
20555
20600
20600
20605
20605
20610
20610
20612
20612
20615
20615
20650
20650
20660
20660
20661
20662
20663
20664
20665
20665
20670
20670
20680
20680
20690
20692
20693
20694
20694
20696
20697
20697
20802
20805
20808
20816
20822
20824
20827
20838
20900
20900
20902
20910
20912
20920
20922
20922
20924
20926
20931
20937
20938
20950
20950
20955
20956
20957
20962
20969
20970
20972
20973
20974
20974
20975
20979
20979
20982
20982
20985
21010
21015
21025
21025
21026
21026
21029
21029
21030
21030
21031
21031
21032
21032
21034
21034
21040
21040
21044
21045
21046
21047
21048
21049
21050
21060
21070
21073
21073
21076
21076
21077
21077
21079
21079
21080
21080
21081
21081
21082
21082
21083
21083
21084
21084
21085
21085
21086
21086
21087
21087
21100
21100
21110
21110
21116
21116
21120
21120
21121
21121
21122
21123
21125
21125
21127
21127
21137
21138
21139
21141
21142
21143
21145
21146
21147
21150
21151
21154
21155
21159
21160
21172
21175
21179
21180
21181
21182
21183
21184
21188
21193
21194
21195
21196
21198
21199
21206
21208
21208
21209
21209
21210
21210
21215
21215
21230
21235
21235
21240
21242
21243
21244
21245
21245
21246
21247
21248
21248
21249
21249
21255
21256
21260
21261
21263
21267
21268
21270
21270
21275
21280
21282
21295
21296
21310
21310
21315
21315
21320
21320
21325
21330
21335
21336
21337
21337
21338






California - MEDICARE CARRIER 01192 FSY2009 LOCALITY 18 FEE SCHEDULE PAGE: 5
PROCEDURE PAR NONPAR LIMITING
CODE/MOD FEE FEE CHARGE
PROCEDURE
CODE/MOD
PAR
FEE
NONPAR
FEE
LIMITING
CHARGE
PROCEDURE
CODE/MOD
PAR
FEE
NONPAR LIMITING
FEE CHARGE
# 20525 250.40 237.88 273.56
20526 77.06 73.21 84.19
# 20526 58.94 55.99 64.39
20550 59.49 56.52 65.00
# 20550 42.70 40.57 46.66
20551 58.76 55.82 64.19
# 20551 43.73 41.54 47.77
20552 53.62 50.94 58.58
# 20552 36.83 34.99 40.24
20553 59.80 56.81 65.33
# 20553 40.81 38.77 44.59
20555 340.68 323.65 372.20
20600 56.26 53.45 61.47
# 20600 41.24 39.18 45.06
20605 60.55 57.52 66.15
# 20605 42.87 40.73 46.84
20610 78.80 74.86 86.09
# 20610 51.41 48.84 56.17
20612 60.11 57.10 65.67
# 20612 44.20 41.99 48.29
20615 221.61 210.53 242.11
# 20615 161.08 153.03 175.98
20650 200.39 190.37 218.93
# 20650 158.85 150.91 173.55
20660 253.89 241.20 277.38
# 20660 237.98 226.08 259.99
20661 475.67 451.89 519.67
20662 485.88 461.59 530.83
20663 450.78 428.24 492.48
20664 768.65 730.22 839.75
20665 124.81 118.57 136.36
# 20665 103.16 98.00 112.70
20670 416.16 395.35 454.65
# 20670 152.84 145.20 166.98
20680 603.14 572.98 658.93
# 20680 416.25 395.44 454.76
20690 540.69 513.66 590.71
20692 1,012.90 962.26 1,106.60
20693 465.96 442.66 509.06
20694 433.65 411.97 473.77
# 20694 341.75 324.66 373.36
20696 1,084.90 1,030.66 1,185.26
20697 1,461.82 1,388.73 1,597.04
# 20697 0.29 0.28 0.32
20802 2,458.42 2,335.50 2,685.83
20805 3,017.68 2,866.80 3,296.82
20808 4,138.81 3,931.87 4,521.65
20816 2,312.27 2,196.66 2,526.16
20822 1,964.83 1,866.59 2,146.58
20824 2,302.07 2,186.97 2,515.02
20827 2,044.60 1,942.37 2,233.73
20838 2,486.65 2,362.32 2,716.67
20900 440.77 418.73 481.54
# 20900 274.21 260.50 299.58
20902 375.34 356.57 410.06
20910 439.76 417.77 480.44
20912 490.79 466.25 536.19
20920 413.50 392.83 451.75
20922 620.84 589.80 678.27
# 20922 505.09 479.84 551.82
20924 512.63 487.00 560.05
20926 442.47 420.35 483.40
20931 114.89 109.15 125.52
20937 174.75 166.01 190.91
20938 189.82 180.33 207.38
20950 259.88 246.89 283.92
# 20950 92.87 88.23 101.46
20955 2,583.51 2,454.33 2,822.48
20956 2,701.97 2,566.87 2,951.90
20957 2,552.90 2,425.26 2,789.05
20962 2,654.54 2,521.81 2,900.08
20969 2,855.66 2,712.88 3,119.81
20970 2,877.41 2,733.54 3,143.57
20972 2,596.73 2,466.89 2,836.92
20973 2,720.57 2,584.54 2,972.22
20974 67.56 64.18 73.81
# 20974 49.00 46.55 53.53
20975
20979
# 20979
20982
# 20982
20985
21010
21015
21025
# 21025
21026
# 21026
21029
# 21029
21030
# 21030
21031
# 21031
21032
# 21032
21034
# 21034
21040
# 21040
21044
21045
21046
21047
21048
21049
21050
21060
21070
21073
# 21073
21076
# 21076
21077
# 21077
21079
# 21079
21080
# 21080
21081
# 21081
21082
# 21082
21083
# 21083
21084
# 21084
21085
# 21085
21086
# 21086
21087
# 21087
21100
# 21100
21110
# 21110
21116
# 21116
21120
# 21120
21121
# 21121
21122
21123
21125
# 21125
21127
# 21127
21137
21138
21139
21141
181.77
54.61
36.49
4,116.44
421.53
154.61
729.94
431.64
899.71
757.00
602.71
492.70
758.87
634.28
502.94
407.95
390.36
293.60
395.68
288.76
1,340.02
1,180.53
507.36
405.30
885.00
1,229.77
1,103.32
1,310.84
1,115.51
1,268.79
875.30
796.46
650.21
376.08
240.44
975.08
840.33
2,398.22
2,125.62
1,645.89
1,407.31
1,871.40
1,583.34
1,708.27
1,441.41
1,593.52
1,338.15
1,517.30
1,238.96
1,724.44
1,416.94
698.65
572.29
1,748.02
1,556.27
1,741.07
1,550.21
740.85
405.95
771.91
651.30
158.51
43.64
639.94
507.84
787.06
664.67
731.74
868.33
3,235.61
752.16
3,854.80
880.50
725.74
905.57
1,011.60
1,362.32
172.68
51.88
34.67
3,910.62
400.45
146.88
693.44
410.06
854.72
719.15
572.57
468.07
720.93
602.57
477.79
387.55
370.84
278.92
375.90
274.32
1,273.02
1,121.50
481.99
385.04
840.75
1,168.28
1,048.15
1,245.30
1,059.73
1,205.35
831.54
756.64
617.70
357.28
228.42
926.33
798.31
2,278.31
2,019.34
1,563.60
1,336.94
1,777.83
1,504.17
1,622.86
1,369.34
1,513.84
1,271.24
1,441.44
1,177.01
1,638.22
1,346.09
663.72
543.68
1,660.62
1,478.46
1,654.02
1,472.70
703.81
385.65
733.31
618.74
150.58
41.46
607.94
482.45
747.71
631.44
695.15
824.91
3,073.83
714.55
3,662.06
836.48
689.45
860.29
961.02
1,294.20
198.58
59.66
39.87
4,497.21
460.52
168.91
797.46
471.57
982.93
827.02
658.46
538.28
829.07
692.96
549.46
445.68
426.47
320.76
432.29
315.47
1,463.97
1,289.73
554.29
442.80
966.86
1,343.52
1,205.37
1,432.10
1,218.69
1,386.15
956.27
870.14
710.36
410.87
262.68
1,065.28
918.06
2,620.06
2,322.24
1,798.14
1,537.48
2,044.50
1,729.80
1,866.29
1,574.74
1,740.92
1,461.93
1,657.66
1,353.56
1,883.95
1,548.00
763.28
625.23
1,909.71
1,700.23
1,902.12
1,693.61
809.38
443.50
843.31
711.55
173.17
47.68
699.13
554.82
859.87
726.16
799.42
948.65
3,534.90
821.73
4,211.37
961.95
792.87
989.33
1,105.17
1,488.33
21142
21143
21145
21146
21147
21150
21151
21154
21155
21159
21160
21172
21175
21179
21180
21181
21182
21183
21184
21188
21193
21194
21195
21196
21198
21199
21206
21208
# 21208
21209
# 21209
21210
# 21210
21215
# 21215
21230
21235
# 21235
21240
21242
21243
21244
21245
# 21245
21246
21247
21248
# 21248
21249
# 21249
21255
21256
21260
21261
21263
21267
21268
21270
# 21270
21275
21280
21282
21295
21296
21310
# 21310
21315
# 21315
21320
# 21320
21325
21330
21335
21336
21337
# 21337
21338
1,338.15
1,389.19
1,552.53
1,663.82
1,706.20
1,694.71
2,070.54
2,074.34
2,351.65
2,839.03
2,900.75
1,789.81
2,165.13
1,487.16
1,697.30
713.41
2,052.68
2,301.31
2,455.74
1,651.31
1,250.73
1,426.49
1,352.42
1,473.83
1,165.07
1,032.34
1,146.77
1,799.10
834.62
835.57
649.56
2,168.03
831.54
3,747.96
866.43
772.09
737.50
572.26
1,118.15
1,025.63
1,679.35
1,059.70
1,154.75
924.12
856.97
1,628.16
1,083.06
884.68
1,493.12
1,249.23
1,467.44
1,176.02
1,342.33
2,265.51
2,036.41
1,568.47
1,935.58
920.85
700.83
811.47
528.69
353.16
178.57
432.17
111.59
28.53
270.15
149.98
258.85
138.68
483.88
588.25
747.88
655.02
400.02
288.69
756.07
1,271.24 1,461.93
1,319.73 1,517.69
1,474.90 1,696.14
1,580.63 1,817.72
1,620.89 1,864.02
1,609.97 1,851.47
1,967.01 2,262.06
1,970.62 2,266.21
2,234.07 2,569.18
2,697.08 3,101.64
2,755.71 3,169.07
1,700.32 1,955.37
2,056.87 2,365.40
1,412.80 1,624.72
1,612.44 1,854.31
677.74 779.40
1,950.05 2,242.56
2,186.24 2,514.18
2,332.95 2,682.89
1,568.74 1,804.05
1,188.19 1,366.42
1,355.17 1,558.45
1,284.80 1,477.52
1,400.14 1,610.16
1,106.82 1,272.84
980.72 1,127.83
1,089.43 1,252.84
1,709.15 1,965.52
792.89 911.82
793.79 912.86
617.08 709.64
2,059.63 2,368.57
789.96 908.45
3,560.56 4,094.64
823.11 946.58
733.49 843.51
700.63 805.72
543.65 625.20
1,062.24 1,221.58
974.35 1,120.50
1,595.38 1,834.69
1,006.72 1,157.73
1,097.01 1,261.56
877.91 1,009.60
814.12 936.24
1,546.75 1,778.76
1,028.91 1,183.25
840.45 966.52
1,418.46 1,631.23
1,186.77 1,364.79
1,394.07 1,603.18
1,117.22 1,284.80
1,275.21 1,466.49
2,152.23 2,475.06
1,934.59 2,224.78
1,490.05 1,713.56
1,838.80 2,114.62
874.81 1,006.03
665.79 765.66
770.90 886.54
502.26 577.60
335.50 385.83
169.64 195.09
410.56 472.14
106.01 121.91
27.10 31.17
256.64 295.14
142.48 163.85
245.91 282.80
131.75 151.51
459.69 528.64
558.84 642.67
710.49 817.06
622.27 715.61
380.02 437.02
274.26 315.40
718.27 826.01
CODES: 20525 - 21338
# - These amounts apply when the service is performed in a facility setting.
C - The payment for the technical component is capped at the OPPS amount.
Limiting charge applies to unassigned claims by non-participating providers. All CPT codes and modifiers are bolded.
All Current Procedural Terminology (CPT) codes and descriptors are copyrighted 2008 by the American Medical Association.

21339
21340
21343
21344
21345
21345
21346
21347
21348
21355
21355
21356
21356
21360
21365
21366
21385
21386
21387
21390
21395
21400
21400
21401
21401
21406
21407
21408
21421
21421
21422
21423
21431
21432
21433
21435
21436
21440
21440
21445
21445
21450
21450
21451
21451
21452
21452
21453
21453
21454
21461
21461
21462
21462
21465
21470
21480
21480
21485
21485
21490
21495
21497
21497
21501
21501
21502
21510
21550
21550
21555
21555
21556
21557
21600
21610
21615
21616
21620
21627
21630
21632
21685
21700
21705
21720
21725
21740
21750
21800
21800
21805
21810
21820
21820
21825
21920
21920
21925
21925
21930
21930
21935
22010
22015
22100
22101
22102
22103
22110
22112
22114
22116
22206
22207
22208
22210
22212
22214
22216
22220
22222
22224
22226
22305
22305
22310
22310
22315
22315
22318
22319
22325
22326
22327
22328
22505
22520
22520
22521
22521
22522
22523
22524
22525
22526
22526
22527
22527
22532
22533
22534
22548
22554
22556
22558
22585
22590
22595
22600
22610
22612
22614
22630
22632
22800
22802
22804
22808
22810
22812
22818
22819
22830
22840
22842
22843
22844
22845
22846
22847
22848
22849
22850
22851
22852
22855
22856
22857
22861
22862
22864
22865
22900
23000
23000
23020
23030
23030
23031
23031
23035
23040
23044
23065
23065
23066
23066
23075
23075
23076
23077
23100
23101
23105
23106
23107
23120
23125
23130
23140
23145
23146
23150
23155
23156
23170
23172
23174
23180
23182






California - MEDICARE CARRIER 01192 FSY2009 LOCALITY 18 FEE SCHEDULE PAGE: 6
PROCEDURE PAR NONPAR CHARGE
CODE/MOD FEE FEE LIMIT
PROCEDURE PAR NONPAR CHARGE
CODE/MOD FEE FEE LIMIT
PROCEDURE PAR NONPAR CHARGE
CODE/MOD FEE FEE LIMIT
21339 835.91 794.11 913.23
21340 810.86 770.32 885.87
21616 865.68 822.40 945.76
21620 527.87 501.48 576.70
22556 1,652.61 1,569.98 1,805.48
22558 1,513.65 1,437.97 1,653.67
21343 1,167.08 1,108.73 1,275.04 21627 557.17 529.31 608.71 22585 347.32 329.95 379.44
21344 1,511.15 1,435.59 1,650.93
21345 813.45 772.78 888.70
21630 1,279.70 1,215.72 1,398.08
21632 1,260.30 1,197.29 1,376.88
22590 1,540.41 1,463.39 1,682.90
22595 1,463.04 1,389.89 1,598.37
# 21345 660.58 627.55 721.68
21346 969.71 921.22 1,059.40
21685 998.91 948.96 1,091.30
21700 425.21 403.95 464.54
22600 1,256.73 1,193.89 1,372.97
22610 1,239.79 1,177.80 1,354.47
21347 1,122.06 1,065.96 1,225.85 21705 650.88 618.34 711.09 22612 1,595.93 1,516.13 1,743.55
21348 1,164.92 1,106.67 1,272.67
21355 444.66 422.43 485.79
21720 412.13 391.52 450.25
21725 537.59 510.71 587.32
22614 405.58 385.30 443.10
22630 1,538.69 1,461.76 1,681.02
# 21355 326.25 309.94 356.43
21356 499.07 474.12 545.24
21740 1,093.56 1,038.88 1,194.71
21750 727.01 690.66 794.26
22632 329.47 313.00 359.95
22800 1,360.30 1,292.29 1,486.13
# 21356 376.69 357.86 411.54
21360 533.26 506.60 582.59
21800 98.61 93.68 107.73
# 21800 100.37 95.35 109.65
22802 2,153.70 2,046.02 2,352.92
22804 2,484.85 2,360.61 2,714.70
21365 1,103.85 1,048.66 1,205.96 21805 262.83 249.69 287.14 22808 1,831.49 1,739.92 2,000.91
21366 1,225.64 1,164.36 1,339.01
21385 719.97 683.97 786.57
21810 503.56 478.38 550.14
21820 131.58 125.00 143.75
22810 2,036.71 1,934.87 2,225.10
22812 2,231.24 2,119.68 2,437.63
21386 666.95 633.60 728.64
21387 750.06 712.56 819.44
# 21820 133.35 126.68 145.68
21825 573.45 544.78 626.50
22818 2,248.51 2,136.08 2,456.49
22819 2,591.65 2,462.07 2,831.38
21390 770.88 732.34 842.19 21920 262.41 249.29 286.68 22830 813.73 773.04 889.00
21395 967.10 918.75 1,056.56
21400 181.24 172.18 198.01
# 21920 160.80 152.76 175.67
21925 423.34 402.17 462.50
22840 791.76 752.17 865.00
22842 793.43 753.76 866.82
# 21400 147.22 139.86 160.84
21401 485.25 460.99 530.14
# 21925 337.19 320.33 368.38
21930 472.44 448.82 516.14
22843 844.24 802.03 922.33
22844 1,035.06 983.31 1,130.81
# 21401 297.48 282.61 325.00
21406 543.04 515.89 593.27
# 21930 373.47 354.80 408.02
21935 1,160.51 1,102.48 1,267.85
22845 757.43 719.56 827.49
22846 786.44 747.12 859.19
21407 641.01 608.96 700.30 22010 906.34 861.02 990.17 22847 867.25 823.89 947.47
21408 878.42 834.50 959.68
21421 747.46 710.09 816.60
22015 901.63 856.55 985.03
22100 822.32 781.20 898.38
22848 377.09 358.24 411.98
22849 1,311.92 1,246.32 1,433.27
# 21421 633.03 601.38 691.59
21422 676.64 642.81 739.23
22101 819.54 778.56 895.34
22102 816.02 775.22 891.50
22850 720.71 684.67 787.37
22851 422.00 400.90 461.04
21423 800.34 760.32 874.37 22103 146.12 138.81 159.63 22852 689.30 654.84 753.07
21431 752.27 714.66 821.86
21432 673.59 639.91 735.90
22110 1,018.62 967.69 1,112.84
22112 982.47 933.35 1,073.35
22855 1,113.44 1,057.77 1,216.44
22856 1,662.49 1,579.37 1,816.28
21433 1,702.15 1,617.04 1,859.60
21435 1,347.05 1,279.70 1,471.66
22114 1,010.85 960.31 1,104.36
22116 145.34 138.07 158.78
22857 1,722.27 1,636.16 1,881.58
22861 2,004.30 1,904.09 2,189.70
21436 1,977.88 1,878.99 2,160.84
21440 550.36 522.84 601.27
22206 2,393.38 2,273.71 2,614.77
22207 2,362.45 2,244.33 2,580.98
22862 1,979.19 1,880.23 2,162.26
22864 1,842.24 1,750.13 2,012.65
# 21440 453.60 430.92 495.56 22208 599.00 569.05 654.41 22865 2,139.75 2,032.76 2,337.67
21445 771.18 732.62 842.51
# 21445 630.24 598.73 688.54
22210 1,773.40 1,684.73 1,937.44
22212 1,467.76 1,394.37 1,603.53
22900 408.09 387.69 445.84
23000 542.35 515.23 592.51
21450 572.30 543.69 625.24
# 21450 474.66 450.93 518.57
22214 1,477.57 1,403.69 1,614.24
22216 381.33 362.26 416.60
# 23000 361.20 343.14 394.61
23020 696.43 661.61 760.85
21451 749.91 712.41 819.27 22220 1,596.10 1,516.30 1,743.75 23030 433.31 411.64 473.39
# 21451 633.27 601.61 691.85
21452 632.82 601.18 691.36
22222 1,439.88 1,367.89 1,573.07
22224 1,577.70 1,498.82 1,723.64
# 23030 258.79 245.85 282.73
23031 398.40 378.48 435.25
# 21452 344.76 327.52 376.65
21453 867.48 824.11 947.73
22226 379.56 360.58 414.67
22305 186.60 177.27 203.86
# 23031 215.05 204.30 234.95
23035 691.75 657.16 755.73
# 21453 765.42 727.15 836.22
21454 556.74 528.90 608.24
# 22305 171.14 162.58 186.97
22310 285.14 270.88 311.51
23040 725.18 688.92 792.26
23044 576.14 547.33 629.43
21461 2,005.44 1,905.17 2,190.95 # 22310 264.38 251.16 288.83 23065 215.99 205.19 235.97
# 21461 937.13 890.27 1,023.81
21462 2,160.30 2,052.29 2,360.13
22315 858.55 815.62 937.96
# 22315 756.05 718.25 825.99
# 23065 167.40 159.03 182.88
23066 515.65 489.87 563.35
# 21462 1,032.78 981.14 1,128.31
21465 915.44 869.67 1,000.12
22318 1,595.08 1,515.33 1,742.63
22319 1,749.73 1,662.24 1,911.58
# 23066 341.13 324.07 372.68
23075 262.49 249.37 286.78
21470 1,191.29 1,131.73 1,301.49 22325 1,398.77 1,328.83 1,528.15 # 23075 178.10 169.20 194.58
21480 94.01 89.31 102.71
# 21480 32.60 30.97 35.62
22326 1,456.11 1,383.30 1,590.80
22327 1,445.03 1,372.78 1,578.70
23076 564.40 536.18 616.61
23077 1,187.16 1,127.80 1,296.97
21485 672.74 639.10 734.97
# 21485 570.24 541.73 622.99
22328 287.00 272.65 313.55
22505 123.06 116.91 134.45
23100 492.09 467.49 537.61
23101 452.17 429.56 493.99
21490 930.19 883.68 1,016.23
21495 697.98 663.08 762.54
22520 2,475.56 2,351.78 2,704.55
# 22520 592.10 562.50 646.88
23105 642.24 610.13 701.65
23106 479.61 455.63 523.97
21497 680.83 646.79 743.81 22521 2,413.57 2,292.89 2,636.82 23107 666.86 633.52 728.55
# 21497 577.88 548.99 631.34
# 21501 317.71 301.82 347.09
# 22521 558.38 530.46 610.03
22522 259.01 246.06 282.97
23120 579.28 550.32 632.87
23125 707.94 672.54 773.42
21501 444.95 422.70 486.11
21502 523.58 497.40 572.01
22523 622.76 591.62 680.36
22524 596.75 566.91 651.95
23130 609.14 578.68 665.48
23140 514.98 489.23 562.61
21510 466.77 443.43 509.94 22525 276.43 262.61 302.00 23145 695.60 660.82 759.94
21550 262.99 249.84 287.32
# 21550 160.94 152.89 175.82
22526 2,098.17 1,993.26 2,292.25
# 22526 345.92 328.62 377.91
23146 604.86 574.62 660.81
23150 658.13 625.22 719.00
21555 434.60 412.87 474.80
# 21555 332.54 315.91 363.30
22527 1,640.71 1,558.67 1,792.47
# 22527 155.76 147.97 170.17
23155 796.94 757.09 870.65
23156 677.93 644.03 740.63
21556 414.91 394.16 453.28
21557 580.13 551.12 633.79
22532 1,731.84 1,645.25 1,892.04
22533 1,630.63 1,549.10 1,781.47
23170 532.33 505.71 581.57
23172 546.59 519.26 597.15
21600 558.34 530.42 609.98 22534 376.02 357.22 410.80 23174 759.30 721.34 829.54
21610 1,071.15 1,017.59 1,170.23
21615 674.35 640.63 736.72
22548 1,847.56 1,755.18 2,018.46
22554 1,285.36 1,221.09 1,404.25
23180 692.13 657.52 756.15
23182 668.33 634.91 730.15
CODES: 21339 - 23182
# - These amounts apply when the service is performed in a facility setting.
C - The payment for the technical component is capped at the OPPS amount.
Limiting charge applies to unassigned claims by non-participating providers. All CPT codes and modifiers are bolded.
All Current Procedural Terminology (CPT) codes and descriptors are copyrighted 2008 by the American Medical Association..

23184
23190
23195
23200
23210
23220
23221
23222
23330
23330
23331
23332
23350
23350
23395
23397
23400
23405
23406
23410
23412
23415
23420
23430
23440
23450
23455
23460
23462
23465
23466
23470
23472
23480
23485
23490
23491
23500
23500
23505
23505
23515
23520
23520
23525
23525
23530
23532
23540
23540
23545
23545
23550
23552
23570
23570
23575
23575
23585
23600
23600
23605
23605
23615
23616
23620
23620
23625
23625
23630
23650
23650
23655
23660
23665
23665
23670
23675
23675
23680
23700
23800
23802
23900
23920
23921
23930
23930
23931
23931
23935
24000
24006
24065
24065
24066
24066
24075
24075
24076
24077
24100
24101
24102
24105
24110
24115
24116
24120
24125
24126
24130
24134
24136
24138
24140
24145
24147
24149
24150
24151
24152
24153
24155
24160
24164
24200
24200
24201
24201
24220
24220
24300
24301
24305
24310
24320
24330
24331
24332
24340
24341
24342
24343
24344
24345
24346
24357
24358
24359
24360
24361
24362
24363
24365
24366
24400
24410
24420
24430
24435
24470
24495
24498
24500
24500
24505
24505
24515
24516
24530
24530
24535
24535
24538
24545
24546
24560
24560
24565
24565
24566
24575
24576
24576
24577
24577
24579
24582
24586
24587
24600
24600
24605
24615
24620
24635
24640
24640
24650
24650
24655
24655
24665
24666
24670
24670
24675
24675
24685
24800
24802
24900
24920
24925
24930
24931
24935
25000
25001
25020
25023
25024
25025
25028
25031
25035
25040
25065
25065
25066






California - MEDICARE CARRIER 01192 FSY2009 LOCALITY 18 FEE SCHEDULE PAGE: 7
PROCEDURE PAR NONPAR LIMITING
CODE/MOD FEE FEE CHARGE
PROCEDURE
CODE/MOD
PAR
FEE
NONPAR
FEE
LIMITING
CHARGE
PROCEDURE
CODE/MOD
PAR
FEE
NONPAR LIMITING
FEE CHARGE
23184 753.02 715.37 822.68
23190 559.89 531.90 611.69
23195 757.90 720.01 828.01
23200 890.13 845.62 972.46
23210 932.04 885.44 1,018.26
23220 1,078.79 1,024.85 1,178.58
23221 1,255.78 1,192.99 1,371.94
23222 1,707.23 1,621.87 1,865.15
23330 228.27 216.86 249.39
# 23330 149.63 142.15 163.47
23331 592.72 563.08 647.54
23332 894.47 849.75 977.21
23350 167.85 159.46 183.38
# 23350 55.63 52.85 60.78
23395 1,299.93 1,234.93 1,420.17
23397 1,162.50 1,104.38 1,270.04
23400 987.78 938.39 1,079.15
23405 637.78 605.89 696.77
23406 794.68 754.95 868.19
23410 845.52 803.24 923.73
23412 883.40 839.23 965.11
23415 706.01 670.71 771.32
23420 989.11 939.65 1,080.60
23430 748.99 711.54 818.27
23440 771.39 732.82 842.74
23450 965.34 917.07 1,054.63
23455 1,029.23 977.77 1,124.44
23460 1,114.58 1,058.85 1,217.68
23462 1,091.87 1,037.28 1,192.87
23465 1,139.92 1,082.92 1,245.36
23466 1,126.43 1,070.11 1,230.63
23470 1,239.13 1,177.17 1,353.75
23472 1,531.05 1,454.50 1,672.68
23480 831.25 789.69 908.14
23485 980.15 931.14 1,070.81
23490 845.92 803.62 924.16
23491 1,032.89 981.25 1,128.44
23500 207.52 197.14 226.71
# 23500 206.19 195.88 225.26
23505 340.58 323.55 372.08
# 23505 321.58 305.50 351.33
23515 706.85 671.51 772.24
23520 215.22 204.46 235.13
# 23520 216.54 205.71 236.57
23525 333.16 316.50 363.98
# 23525 310.18 294.67 338.87
23530 540.81 513.77 590.84
23532 625.26 594.00 683.10
23540 211.98 201.38 231.59
# 23540 208.88 198.44 228.21
23545 306.22 290.91 334.55
# 23545 280.60 266.57 306.56
23550 576.43 547.61 629.75
23552 663.23 630.07 724.58
23570 221.96 210.86 242.49
# 23570 225.05 213.80 245.87
23575 377.68 358.80 412.62
# 23575 354.71 336.97 387.52
23585 951.11 903.55 1,039.08
23600 311.68 296.10 340.52
# 23600 286.93 272.58 313.47
23605 457.25 434.39 499.55
# 23605 420.14 399.13 459.00
23615 876.24 832.43 957.29
23616 1,308.05 1,242.65 1,429.05
23620 256.83 243.99 280.59
# 23620 241.37 229.30 263.70
23625 370.70 352.17 405.00
# 23625 346.84 329.50 378.93
23630 752.54 714.91 822.15
23650 285.86 271.57 312.31
# 23650 259.80 246.81 283.83
23655 379.78 360.79 414.91
23660 584.64 555.41 638.72
23665 411.95 391.35 450.05
# 23665 386.33 367.01 422.06
23670 842.20 800.09 920.10
# 23675
23675
23680
23700
23800
23802
23900
23920
23921
23930
# 23930
23931
# 23931
23935
24000
24006
24065
# 24065
24066
# 24066
24075
# 24075
24076
24077
24100
24101
24102
24105
24110
24115
24116
24120
24125
24126
24130
24134
24136
24138
24140
24145
24147
24149
24150
24151
24152
24153
24155
24160
24164
24200
# 24200
24201
# 24201
24220
# 24220
24300
24301
24305
24310
24320
24330
24331
24332
24340
24341
24342
24343
24344
24345
24346
24357
24358
24359
24360
24361
24362
24363
494.49
536.90
912.97
196.49
1,038.60
1,258.27
1,334.90
1,085.69
394.51
359.09
216.83
283.73
158.70
499.58
474.82
715.28
256.52
167.72
592.70
398.30
482.58
312.48
474.87
815.61
406.02
499.97
617.60
338.83
585.83
736.09
872.72
524.17
604.01
641.28
507.42
759.01
597.80
666.62
724.34
608.55
634.37
1,162.91
983.99
1,128.89
740.19
787.48
856.18
608.74
498.09
198.99
135.37
558.46
364.50
182.72
73.59
397.05
759.41
581.73
476.91
781.08
722.27
797.99
607.51
617.53
727.88
793.39
707.27
1,097.34
702.26
1,100.00
444.99
523.55
654.97
911.02
1,020.33
1,078.60
1,505.13
469.77
510.06
867.32
186.67
986.67
1,195.36
1,268.16
1,031.41
374.78
341.14
205.99
269.54
150.77
474.60
451.08
679.52
243.69
159.33
563.07
378.39
458.45
296.86
451.13
774.83
385.72
474.97
586.72
321.89
556.54
699.29
829.08
497.96
573.81
609.22
482.05
721.06
567.91
633.29
688.12
578.12
602.65
1,104.76
934.79
1,072.45
703.18
748.11
813.37
578.30
473.19
189.04
128.60
530.54
346.28
173.58
69.91
377.20
721.44
552.64
453.06
742.03
686.16
758.09
577.13
586.65
691.49
753.72
671.91
1,042.47
667.15
1,045.00
422.74
497.37
622.22
865.47
969.31
1,024.67
1,429.87
540.24
586.57
997.42
214.67
1,134.67
1,374.66
1,458.38
1,186.12
431.00
392.31
236.89
309.97
173.39
545.79
518.74
781.45
280.24
183.23
647.53
435.15
527.22
341.39
518.80
891.05
443.58
546.22
674.73
370.17
640.02
804.18
953.44
572.65
659.88
700.60
554.36
829.22
653.10
728.28
791.34
664.84
693.05
1,270.47
1,075.01
1,233.32
808.66
860.33
935.38
665.05
544.17
217.40
147.89
610.12
398.22
199.62
80.40
433.78
829.66
635.54
521.02
853.33
789.08
871.80
663.70
674.65
795.21
866.78
772.70
1,198.84
767.22
1,201.75
486.15
571.98
715.55
995.29
1,114.71
1,178.37
1,644.35
24365
24366
24400
24410
24420
24430
24435
24470
24495
24498
24500
# 24500
24505
# 24505
24515
24516
24530
# 24530
24535
# 24535
24538
24545
24546
24560
# 24560
24565
# 24565
24566
24575
24576
# 24576
24577
# 24577
24579
24582
24586
24587
24600
# 24600
24605
24615
24620
24635
24640
# 24640
# 24650
24650
24655
# 24655
24665
24666
24670
# 24670
24675
# 24675
24685
24800
24802
24900
24920
24925
24930
24931
24935
25000
25001
25020
25023
25024
25025
25028
25031
25035
25040
25065
# 25065
25066
644.93
690.04
833.08
1,060.19
998.99
1,056.53
1,075.93
632.59
664.83
883.28
339.05
305.47
489.78
445.60
886.92
875.65
364.85
328.62
610.55
565.92
751.08
918.97
1,070.78
305.19
268.96
502.49
462.72
704.36
745.60
321.66
287.19
522.75
479.89
844.36
785.81
1,111.17
1,105.86
352.36
318.78
457.19
722.38
549.63
769.87
117.77
84.19
223.39
248.58
425.31
387.76
653.48
739.61
278.72
248.68
448.98
411.43
656.73
798.23
1,012.30
722.20
717.14
560.59
760.03
840.17
1,018.66
354.53
332.61
585.57
1,111.72
769.97
1,177.97
521.59
381.54
657.92
576.65
255.22
165.97
382.27
612.68 704.58
655.54 753.87
791.43 910.14
1,007.18 1,158.26
949.04 1,091.40
1,003.70 1,154.26
1,022.13 1,175.45
600.96 691.10
631.59 726.33
839.12 964.99
322.10 370.42
290.20 333.73
465.29 535.08
423.32 486.82
842.57 968.96
831.87 956.65
346.61 398.60
312.19 359.02
580.02 667.02
537.62 618.26
713.53 820.56
873.02 1,003.97
1,017.24 1,169.83
289.93 333.42
255.51 293.84
477.37 548.98
439.58 505.52
669.14 769.51
708.32 814.57
305.58 351.42
272.83 313.75
496.61 571.10
455.90 524.29
802.14 922.46
746.52 858.50
1,055.61 1,213.95
1,050.57 1,208.16
334.74 384.95
302.84 348.27
434.33 499.48
686.26 789.20
522.15 600.47
731.38 841.09
111.88 128.66
79.98 91.98
212.22 244.05
236.15 271.57
404.04 464.65
368.37 423.63
620.81 713.93
702.63 808.02
264.78 304.50
236.25 271.69
426.53 490.51
390.86 449.49
623.89 717.47
758.32 872.07
961.69 1,105.94
686.09 789.00
681.28 783.47
532.56 612.44
722.03 830.33
798.16 917.88
967.73 1,112.89
336.80 387.32
315.98 363.38
556.29 639.73
1,056.13 1,214.55
731.47 841.19
1,119.07 1,286.93
495.51 569.84
362.46 416.83
625.02 718.77
547.82 629.99
242.46 278.83
157.67 181.32
363.16 417.63
CODES: 23184 - 25066
# - These amounts apply when the service is performed in a facility setting.
C - The payment for the technical component is capped at the OPPS amount.
Limiting charge applies to unassigned claims by non-participating providers. All CPT codes and modifiers are bolded.
All Current Procedural Terminology (CPT) codes and descriptors are copyrighted 2008 by the American Medical Association.

25075
25076
25077
25085
25100
25101
25105
25107
25109
25110
25111
25112
25115
25116
25118
25119
25120
25125
25126
25130
25135
25136
25145
25150
25151
25170
25210
25215
25230
25240
25246
25246
25248
25250
25251
25259
25260
25263
25265
25270
25272
25274
25275
25280
25290
25295
25300
25301
25310
25312
25315
25316
25320
25332
25335
25337
25350
25355
25360
25365
25370
25375
25390
25391
25392
25393
25394
25400
25405
25415
25420
25425
25426
25430
25431
25440
25441
25442
25443
25444
25445
25446
25447
25449
25450
25455
25490
25491
25492
25500
25500
25505
25505
25515
25520
25520
25525
25526
25530
25530
25535
25535
25545
25560
25560
25565
25565
25574
25575
25600
25600
25605
25605
25606
25607
25608
25609
25622
25622
25624
25624
25628
25630
25630
25635
25635
25645
25650
25650
25651
25652
25660
25670
25671
25675
25675
25676
25680
25685
25690
25695
25800
25805
25810
25820
25825
25830
25900
25905
25907
25909
25915
25920
25922
25924
25927
25929
25931
26010
26010
26011
26011
26020
26025
26030
26034
26035
26037
26040
26045
26055
26055
26060
26070
26075
26080
26100
26105
26110
26115
26115
26116
26117
26121
26123
26125
26130
26135
26140
26145
26160
26160
26170
26180
26185
26200
26205
26210
26215
26230
26235
26236
26250
26255
26260
26261
26262
26320
26340
26350
26352
26356
26357
26358
26370
26372
26373
26390
26392
26410
26412
26415
26416
26418
26420
26426
26428
26432
26433
26434
26437






California - MEDICARE CARRIER 01192 FSY2009 LOCALITY 18 FEE SCHEDULE PAGE: 8
PROCEDURE PAR NONPAR CHARGE
CODE/MOD FEE FEE LIMIT
PROCEDURE PAR NONPAR CHARGE
CODE/MOD FEE FEE LIMIT
PROCEDURE PAR NONPAR CHARGE
CODE/MOD FEE FEE LIMIT
25075 333.71 317.02 364.57
25076 451.94 429.34 493.74
25442 812.28 771.67 887.42
25443 779.32 740.35 851.40
25924 675.08 641.33 737.53
25927 793.27 753.61 866.65
25077 755.72 717.93 825.62 25444 830.82 789.28 907.67 25929 562.00 533.90 613.99
25085 467.63 444.25 510.89
25100 348.39 330.97 380.62
25445 728.17 691.76 795.52
25446 1,191.59 1,132.01 1,301.81
25931 724.74 688.50 791.78
26010 258.19 245.28 282.07
25101 410.02 389.52 447.95
25105 497.31 472.44 543.31
25447 822.31 781.19 898.37
25449 1,045.51 993.23 1,142.21
# 26010 132.27 125.66 144.51
26011 395.19 375.43 431.74
25107 617.36 586.49 674.46 25450 611.91 581.31 668.51 # 26011 184.44 175.22 201.50
25109 524.31 498.09 572.80
25110 366.36 348.04 400.25
25455 693.77 659.08 757.94
25490 772.08 733.48 843.50
26020 426.47 405.15 465.92
26025 415.72 394.93 454.17
25111 317.72 301.83 347.10
25112 385.77 366.48 421.45
25491 815.75 774.96 891.20
25492 979.97 930.97 1,070.62
26030 489.47 465.00 534.75
26034 531.86 505.27 581.06
25115 814.01 773.31 889.31
25116 662.72 629.58 724.02
25500 253.28 240.62 276.71
# 25500 229.42 217.95 250.64
26035 821.40 780.33 897.38
26037 569.42 540.95 622.09
25118 388.02 368.62 423.91 25505 491.94 467.34 537.44 26040 307.07 291.72 335.48
25119 512.23 486.62 559.61
25120 566.46 538.14 618.86
# 25505 452.18 429.57 494.01
25515 674.03 640.33 736.38
26045 465.07 441.82 508.09
26055 579.29 550.33 632.88
25125 656.61 623.78 717.35
25126 663.12 629.96 724.45
25520 539.24 512.28 589.12
# 25520 512.29 486.68 559.68
# 26055 296.09 281.29 323.48
26060 263.20 250.04 287.55
25130 454.45 431.73 496.49 25525 815.17 774.41 890.57 26070 296.23 281.42 323.63
25135 565.26 537.00 617.55
25136 500.59 475.56 546.89
25526 999.27 949.31 1,091.71
25530 247.43 235.06 270.32
26075 314.69 298.96 343.80
26080 381.65 362.57 416.96
25145 580.86 551.82 634.59
25150 585.68 556.40 639.86
# 25530 220.92 209.87 241.35
25535 476.28 452.47 520.34
26100 320.19 304.18 349.81
26105 328.00 311.60 358.34
25151 651.56 618.98 711.83
25170 901.08 856.03 984.43
# 25535 444.47 422.25 485.59
25545 632.93 601.28 691.47
26110 315.09 299.34 344.24
26115 631.29 599.73 689.69
25210 496.81 471.97 542.77 25560 256.88 244.04 280.65 # 26115 358.24 340.33 391.38
25215 638.26 606.35 697.30
25230 440.29 418.28 481.02
# 25560 228.16 216.75 249.26
25565 513.95 488.25 561.49
26116 479.75 455.76 524.12
26117 648.24 615.83 708.20
25240 447.45 425.08 488.84
25246 184.74 175.50 201.83
# 25565 468.00 444.60 511.29
25574 662.12 629.01 723.36
26121 597.99 568.09 653.30
26123 817.00 776.15 892.57
# 25246 80.91 76.86 88.39 25575 898.52 853.59 981.63 26125 286.67 272.34 313.19
25248 445.42 423.15 486.62
25250 526.31 499.99 574.99
25600 280.18 266.17 306.10
# 25600 251.46 238.89 274.72
26130 454.80 432.06 496.87
26135 551.29 523.73 602.29
25251 714.86 679.12 780.99
25259 398.39 378.47 435.24
25605 601.84 571.75 657.51
# 25605 567.38 539.01 619.86
26140 502.26 477.15 548.72
26145 510.22 484.71 557.42
25260 692.15 657.54 756.17
25263 690.91 656.36 754.81
25606 666.71 633.37 728.38
25607 716.10 680.30 782.35
26160 576.65 547.82 629.99
# 26160 321.28 305.22 351.00
25265 815.98 775.18 891.46 25608 815.43 774.66 890.86 26170 402.44 382.32 439.67
25270 557.72 529.83 609.30
25272 625.70 594.42 683.58
25609 1,039.20 987.24 1,135.33
25622 287.91 273.51 314.54
26180 440.26 418.25 480.99
26185 525.86 499.57 574.51
25274 738.62 701.69 806.94
25275 675.31 641.54 737.77
# 25622 257.43 244.56 281.24
25624 453.08 430.43 494.99
26200 450.76 428.22 492.45
26205 603.21 573.05 659.01
25280 633.36 601.69 691.94 # 25624 411.55 390.97 449.62 26210 438.10 416.20 478.63
25290 542.82 515.68 593.03
25295 590.86 561.32 645.52
25628 718.42 682.50 784.88
25630 293.53 278.85 320.68
26215 553.05 525.40 604.21
26230 503.43 478.26 550.00
25300 688.93 654.48 752.65
25301 655.85 623.06 716.52
# 25630 263.49 250.32 287.87
25635 427.87 406.48 467.45
26235 494.67 469.94 540.43
26236 439.39 417.42 480.03
25310 685.32 651.05 748.71
25312 789.90 750.41 862.97
# 25635 379.27 360.31 414.36
25645 568.16 539.75 620.71
26250 582.72 553.58 636.62
26255 878.18 834.27 959.41
25315 845.67 803.39 923.90 25650 305.59 290.31 333.86 26260 545.99 518.69 596.49
25316 974.29 925.58 1,064.42
25320 970.99 922.44 1,060.81
# 25650 279.97 265.97 305.87
25651 472.80 449.16 516.53
26261 673.08 639.43 735.34
26262 457.21 434.35 499.50
25332 852.50 809.88 931.36
25335 967.42 919.05 1,056.91
25652 619.63 588.65 676.95
25660 394.26 374.55 430.73
26320 343.00 325.85 374.73
26340 315.12 299.36 344.26
25337 893.28 848.62 975.91 25670 612.42 581.80 669.07 26350 730.26 693.75 797.81
25350 752.89 715.25 822.54
25355 844.24 802.03 922.33
25671 519.89 493.90 567.99
25675 418.99 398.04 457.75
26352 824.32 783.10 900.57
26356 1,076.66 1,022.83 1,176.25
25360 731.23 694.67 798.87
25365 987.88 938.49 1,079.26
# 25675 384.09 364.89 419.62
25676 634.99 603.24 693.73
26357 882.91 838.76 964.57
26358 933.15 886.49 1,019.46
25370 1,076.73 1,022.89 1,176.32
25375 1,039.40 987.43 1,135.54
25680 451.92 429.32 493.72
25685 735.30 698.54 803.32
26370 786.35 747.03 859.08
26372 907.65 862.27 991.61
25390 848.45 806.03 926.93 25690 460.79 437.75 503.41 26373 863.84 820.65 943.75
25391 1,073.31 1,019.64 1,172.59
25392 1,088.90 1,034.46 1,189.63
25695 635.54 603.76 694.32
25800 751.79 714.20 821.33
26390 839.47 797.50 917.13
26392 985.31 936.04 1,076.45
25393 1,222.14 1,161.03 1,335.18
25394 782.67 743.54 855.07
25805 865.83 822.54 945.92
25810 873.81 830.12 954.64
26410 581.70 552.62 635.51
26412 701.60 666.52 766.50
25400 889.59 845.11 971.88 25820 619.04 588.09 676.30 26415 725.97 689.67 793.12
25405 1,126.00 1,069.70 1,230.16
25415 1,060.31 1,007.29 1,158.38
25825 760.92 722.87 831.30
25830 960.14 912.13 1,048.95
26416 774.53 735.80 846.17
26418 586.70 557.37 640.98
25420 1,257.52 1,194.64 1,373.84
25425 1,094.91 1,040.16 1,196.18
25900 758.70 720.77 828.89
25905 749.10 711.65 818.40
26420 727.51 691.13 794.80
26426 580.58 551.55 634.28
25426 1,130.77 1,074.23 1,235.36
25430 715.13 679.37 781.28
25907 656.24 623.43 716.94
25909 737.53 700.65 805.75
26428 763.98 725.78 834.65
26432 508.92 483.47 555.99
25431 790.80 751.26 863.95 25915 1,281.22 1,217.16 1,399.73 26433 544.32 517.10 594.67
25440 787.04 747.69 859.84
25441 951.23 903.67 1,039.22
25920 691.27 656.71 755.22
25922 584.19 554.98 638.23
26434 648.88 616.44 708.91
26437 633.16 601.50 691.73
CODES: 25075 - 26437
# - These amounts apply when the service is performed in a facility setting.
C - The payment for the technical component is capped at the OPPS amount.
Limiting charge applies to unassigned claims by non-participating providers. All CPT codes and modifiers are bolded.
All Current Procedural Terminology (CPT) codes and descriptors are copyrighted 2008 by the American Medical Association..

26440
26442
26445
26449
26450
26455
26460
26471
26474
26476
26477
26478
26479
26480
26483
26485
26489
26490
26492
26494
26496
26497
26498
26499
26500
26502
26508
26510
26516
26517
26518
26520
26525
26530
26531
26535
26536
26540
26541
26542
26545
26546
26548
26550
26551
26553
26554
26555
26556
26560
26561
26562
26565
26567
26568
26580
26587
26590
26591
26593
26596
26600
26600
26605
26605
26607
26608
26615
26641
26641
26645
26645
26650
26665
26670
26670
26675
26675
26676
26685
26686
26700
26700
26705
26705
26706
26715
26720
26720
26725
26725
26727
26735
26740
26740
26742
26742
26746
26750
26750
26755
26755
26756
26765
26770
26770
26775
26775
26776
26785
26820
26841
26842
26843
26844
26850
26852
26860
26861
26862
26863
26910
26951
26952
26990
26991
26991
26992
27000
27001
27003
27005
27006
27025
27027
27030
27033
27035
27036
27040
27040
27041
27047
27047
27048
27049
27050
27052
27054
27057
27060
27062
27065
27066
27067
27070
27071
27075
27076
27077
27078
27079
27080
27086
27086
27087
27090
27091
27093
27093
27095
27095
27096
27096
27097
27098
27100
27105
27110
27111
27120
27122
27125
27130
27132
27134
27137
27138
27140
27146
27147
27151
27156
27158
27161
27165
27170
27175
27176
27177
27178
27179
27181
27185
27187
27193
27193
27194
27200
27200
27202
27220
27220
27222
27226
27227
27228
27230
27230
27232
27235
27236
27238
27240
27244
27245
27246
27246
27248
27250
27252






California - MEDICARE CARRIER 01192 FSY2009 LOCALITY 18 FEE SCHEDULE PAGE: 9
PROCEDURE PAR NONPAR LIMITING
CODE/MOD FEE FEE CHARGE
PROCEDURE
CODE/MOD
PAR
FEE
NONPAR
FEE
LIMITING
CHARGE
PROCEDURE
CODE/MOD
PAR
FEE
NONPAR LIMITING
FEE CHARGE
26440 641.99 609.89 701.37
26442 959.65 911.67 1,048.42
26445 598.29 568.38 653.64
26449 765.36 727.09 836.15
26450 409.12 388.66 446.96
26455 406.38 386.06 443.97
26460 395.66 375.88 432.26
26471 623.75 592.56 681.44
26474 599.58 569.60 655.04
26476 583.70 554.52 637.70
26477 589.34 559.87 643.85
26478 638.45 606.53 697.51
26479 631.47 599.90 689.89
26480 770.26 731.75 841.51
26483 864.69 821.46 944.68
26485 830.07 788.57 906.86
26489 888.23 843.82 970.39
26490 795.29 755.53 868.86
26492 884.60 840.37 966.43
26494 805.31 765.04 879.80
26496 870.85 827.31 951.41
26497 871.59 828.01 952.21
26498 1,156.30 1,098.49 1,263.26
26499 834.00 792.30 911.15
26500 636.06 604.26 694.90
26502 715.31 679.54 781.47
26508 639.37 607.40 698.51
26510 608.11 577.70 664.36
26516 713.05 677.40 779.01
26517 836.34 794.52 913.70
26518 843.50 801.33 921.53
26520 670.68 637.15 732.72
26525 673.42 639.75 735.71
26530 534.92 508.17 584.40
26531 621.98 590.88 679.51
26535 399.40 379.43 436.34
26536 682.73 648.59 745.88
26540 671.34 637.77 733.44
26541 815.36 774.59 890.78
26542 693.30 658.64 757.44
26545 705.55 670.27 770.81
26546 985.84 936.55 1,077.03
26548 774.10 735.40 845.71
26550 1,485.79 1,411.50 1,623.23
26551 3,226.28 3,064.97 3,524.72
26553 2,783.91 2,644.71 3,041.42
26554 3,680.53 3,496.50 4,020.98
26555 1,385.08 1,315.83 1,513.20
26556 2,876.61 2,732.78 3,142.70
26560 579.32 550.35 632.90
26561 913.34 867.67 997.82
26562 1,326.63 1,260.30 1,449.35
26565 686.80 652.46 750.33
26567 693.61 658.93 757.77
26568 912.51 866.88 996.91
26580 1,394.99 1,325.24 1,524.03
26587 948.02 900.62 1,035.71
26590 1,264.23 1,201.02 1,381.17
26591 449.30 426.84 490.87
26593 607.22 576.86 663.39
26596 736.67 699.84 804.82
26600 268.38 254.96 293.20
# 26600 246.73 234.39 269.55
26605 309.40 293.93 338.02
# 26605 280.69 266.66 306.66
26607 435.63 413.85 475.93
26608 474.60 450.87 518.50
26615 546.37 519.05 596.91
26641 350.96 333.41 383.42
# 26641 318.71 302.77 348.19
26645 401.54 381.46 438.68
# 26645 368.40 349.98 402.48
26650 476.60 452.77 520.69
26665 605.82 575.53 661.86
26670 316.08 300.28 345.32
# 26670 282.95 268.80 309.12
26675 428.91 407.46 468.58
# 26675
26676
26685
26686
26700
# 26700
26705
# 26705
26706
26715
26720
# 26720
26725
# 26725
26727
26735
26740
# 26740
26742
# 26742
26746
26750
# 26750
26755
# 26755
26756
26765
26770
# 26770
26775
# 26775
26776
26785
26820
26841
26842
26843
26844
26850
26852
26860
26861
26862
26863
26910
26951
26952
26990
26991
# 26991
26992
27000
27001
27003
27005
27006
27025
27027
27030
27033
27035
27036
27040
# 27040
27041
27047
# 27047
27048
27049
27050
27052
27054
27057
27060
27062
27065
27066
394.45
498.20
561.88
620.01
300.34
278.25
393.80
359.78
429.54
547.65
186.10
169.31
330.42
294.63
466.79
569.63
216.69
202.55
360.74
325.83
692.63
172.88
168.02
303.20
261.67
412.92
464.66
255.64
232.22
368.77
329.00
438.45
505.39
798.01
742.32
802.74
743.70
827.61
706.45
806.33
572.78
108.06
735.82
240.93
721.89
629.47
658.16
620.45
706.09
521.41
970.93
450.79
545.42
584.90
736.92
745.13
898.77
873.59
958.57
992.67
1,100.11
1,015.73
348.29
203.81
691.60
623.31
515.95
477.45
1,001.84
349.71
559.20
685.67
966.21
431.07
452.87
504.36
816.04
374.73
473.29
533.79
589.01
285.32
264.34
374.11
341.79
408.06
520.27
176.80
160.84
313.90
279.90
443.45
541.15
205.86
192.42
342.70
309.54
658.00
164.24
159.62
288.04
248.59
392.27
441.43
242.86
220.61
350.33
312.55
416.53
480.12
758.11
705.20
762.60
706.52
786.23
671.13
766.01
544.14
102.66
699.03
228.88
685.80
598.00
625.25
589.43
670.79
495.34
922.38
428.25
518.15
555.66
700.07
707.87
853.83
829.91
910.64
943.04
1,045.10
964.94
330.88
193.62
657.02
592.14
490.15
453.58
951.75
332.22
531.24
651.39
917.90
409.52
430.23
479.14
775.24
430.94
544.28
613.86
677.36
328.12
303.99
430.23
393.06
469.27
598.31
203.32
184.97
360.99
321.89
509.97
622.32
236.74
221.28
394.11
355.97
756.70
188.88
183.56
331.25
285.88
451.11
507.64
279.29
253.70
402.88
359.43
479.01
552.14
871.83
810.98
876.99
812.50
904.16
771.80
880.91
625.76
118.06
803.88
263.21
788.67
687.70
719.04
677.84
771.41
569.64
1,060.74
492.49
595.87
639.01
805.08
814.05
981.90
954.40
1,047.24
1,084.50
1,201.87
1,109.68
380.51
222.66
755.57
680.96
563.67
521.62
1,094.51
382.05
610.93
749.10
1,055.59
470.95
494.76
551.01
891.53
27067
27070
27071
27075
27076
27077
27078
27079
27080
27086
# 27086
27087
27090
27091
27093
# 27093
27095
# 27095
27096
# 27096
27097
27098
27100
27105
27110
27111
27120
27122
27125
27130
27132
27134
27137
27138
27140
27146
27147
27151
27156
27158
27161
27165
27170
27175
27176
27177
27178
27179
27181
27185
27187
27193
# 27193
27194
27200
# 27200
27202
27220
# 27220
27222
27226
27227
27228
27230
# 27230
27232
27235
27236
27238
27240
27244
27245
27246
# 27246
27248
27250
27252
1,031.89
855.81
918.83
2,331.54
1,616.27
2,694.64
1,026.76
975.98
494.35
250.96
149.34
636.49
842.63
1,621.00
205.89
74.67
249.03
85.12
187.43
70.35
672.20
623.03
829.60
867.64
966.70
860.14
1,306.85
1,121.94
1,140.82
1,468.94
1,715.10
1,986.10
1,516.23
1,577.70
912.34
1,281.15
1,492.66
1,547.24
1,738.10
1,397.15
1,241.57
1,385.45
1,199.45
669.48
925.78
1,127.31
915.09
985.51
1,093.94
696.86
1,011.13
465.76
470.17
720.99
171.11
175.09
653.30
525.01
521.03
989.91
1,049.47
1,699.14
1,944.41
469.16
462.53
782.43
924.58
1,206.03
452.73
965.92
1,240.22
1,289.80
383.41
384.30
763.74
237.39
762.10
980.30 1,127.35
813.02 934.97
872.89 1,003.82
2,214.96 2,547.20
1,535.46 1,765.78
2,559.91 2,943.90
975.42 1,121.73
927.18 1,066.26
469.63 540.07
238.41 274.17
141.87 163.15
604.67 695.37
800.50 920.58
1,539.95 1,770.94
195.60 224.94
70.94 81.58
236.58 272.07
80.86 92.99
178.06 204.77
66.83 76.85
638.59 734.38
591.88 680.66
788.12 906.34
824.26 947.90
918.37 1,056.13
817.13 939.70
1,241.51 1,427.74
1,065.84 1,225.72
1,083.78 1,246.35
1,395.49 1,604.81
1,629.35 1,873.75
1,886.80 2,169.82
1,440.42 1,656.48
1,498.82 1,723.64
866.72 996.73
1,217.09 1,399.65
1,418.03 1,630.73
1,469.88 1,690.36
1,651.20 1,898.88
1,327.29 1,526.38
1,179.49 1,356.41
1,316.18 1,513.61
1,139.48 1,310.40
636.01 731.41
879.49 1,011.41
1,070.94 1,231.58
869.34 999.74
936.23 1,076.66
1,039.24 1,195.13
662.02 761.32
960.57 1,104.66
442.47 508.84
446.66 513.66
684.94 787.68
162.55 186.93
166.34 191.29
620.64 713.74
498.76 573.57
494.98 569.23
940.41 1,081.47
997.00 1,146.55
1,614.18 1,856.31
1,847.19 2,124.27
445.70 512.56
439.40 505.31
743.31 854.81
878.35 1,010.10
1,145.73 1,317.59
430.09 494.60
917.62 1,055.26
1,178.21 1,354.94
1,225.31 1,409.11
364.24 418.88
365.09 419.85
725.55 834.38
225.52 259.35
724.00 832.60
CODES: 26440 - 27252
# - These amounts apply when the service is performed in a facility setting.
C - The payment for the technical component is capped at the OPPS amount.
Limiting charge applies to unassigned claims by non-participating providers. All CPT codes and modifiers are bolded.
All Current Procedural Terminology (CPT) codes and descriptors are copyrighted 2008 by the American Medical Association.

27253
27254
27256
27256
27257
27258
27259
27265
27266
27267
27268
27269
27275
27280
27282
27284
27286
27290
27295
27301
27301
27303
27305
27306
27307
27310
27323
27323
27324
27325
27326
27327
27327
27328
27329
27330
27331
27332
27333
27334
27335
27340
27345
27347
27350
27355
27356
27357
27358
27360
27365
27370
27370
27372
27372
27380
27381
27385
27386
27390
27391
27392
27393
27394
27395
27396
27397
27400
27403
27405
27407
27409
27412
27415
27416
27418
27420
27422
27424
27425
27427
27428
27429
27430
27435
27437
27438
27440
27441
27442
27443
27445
27446
27447
27448
27450
27454
27455
27457
27465
27466
27468
27470
27472
27475
27477
27479
27485
27486
27487
27488
27495
27496
27497
27498
27499
27500
27500
27501
27501
27502
27503
27506
27507
27508
27508
27509
27510
27511
27513
27514
27516
27516
27517
27519
27520
27520
27524
27530
27530
27532
27532
27535
27536
27538
27538
27540
27550
27550
27552
27556
27557
27558
27560
27560
27562
27566
27570
27580
27590
27591
27592
27594
27596
27598
27600
27601
27602
27603
27603
27604
27604
27605
27605
27606
27607
27610
27612
27613
27613
27614
27614
27615
27618
27618
27619
27619
27620
27625
27626
27630
27630
27635
27637
27638
27640
27641
27645
27646
27647
27648
27648
27650
27652
27654
27656
27656
27658
27659
27664
27665
27675
27676
27680
27681
27685
27685
27686
27687
27690
27691
27692
27695
27696
27698
27700
27702
27703
27704
27705
27707






California - MEDICARE CARRIER 01192 FSY2009 LOCALITY 18 FEE SCHEDULE PAGE: 10
PROCEDURE PAR NONPAR CHARGE
CODE/MOD FEE FEE LIMIT
PROCEDURE PAR NONPAR CHARGE
CODE/MOD FEE FEE LIMIT
PROCEDURE PAR NONPAR CHARGE
CODE/MOD FEE FEE LIMIT
27253 960.29 912.28 1,049.12
27254 1,294.22 1,229.51 1,413.94
27422 753.15 715.49 822.81
27424 755.16 717.40 825.01
# 27560 322.07 305.97 351.87
27562 461.55 438.47 504.24
27256 292.20 277.59 319.23 27425 443.92 421.72 484.98 27566 907.35 861.98 991.28
# 27256 242.71 230.57 265.16
27257 336.63 319.80 367.77
27427 725.34 689.07 792.43
27428 1,114.80 1,059.06 1,217.92
27570 149.00 141.55 162.78
27580 1,468.12 1,394.71 1,603.92
27258 1,124.42 1,068.20 1,228.43
27259 1,573.84 1,495.15 1,719.42
27429 1,248.09 1,185.69 1,363.54
27430 748.33 710.91 817.55
27590 831.20 789.64 908.09
27591 927.22 880.86 1,012.99
27265 390.76 371.22 426.90 27435 803.29 763.13 877.60 27592 708.25 672.84 773.77
27266 583.40 554.23 637.36
27267 416.90 396.06 455.47
27437 665.95 632.65 727.55
27438 850.87 808.33 929.58
27594 516.59 490.76 564.37
27596 743.38 706.21 812.14
27268 514.27 488.56 561.84
27269 1,225.89 1,164.60 1,339.29
27440 775.69 736.91 847.45
27441 800.36 760.34 874.39
27598 757.21 719.35 827.25
27600 429.10 407.65 468.80
27275 181.67 172.59 198.48
27280 1,042.71 990.57 1,139.16
27442 880.91 836.86 962.39
27443 826.10 784.80 902.52
27601 446.36 424.04 487.65
27602 523.28 497.12 571.69
27282 814.64 773.91 890.00 27445 1,281.98 1,217.88 1,400.56 27603 528.70 502.27 577.61
27284 1,567.46 1,489.09 1,712.45
27286 1,665.81 1,582.52 1,819.90
27446 1,137.76 1,080.87 1,243.00
27447 1,573.45 1,494.78 1,719.00
# 27603 390.42 370.90 426.54
27604 463.71 440.52 506.60
27290 1,586.82 1,507.48 1,733.60
27295 1,282.49 1,218.37 1,401.13
27448 831.30 789.74 908.20
27450 1,035.24 983.48 1,131.00
# 27604 343.97 326.77 375.79
27605 374.44 355.72 409.08
27301 665.85 632.56 727.44 27454 1,301.81 1,236.72 1,422.23 # 27605 204.78 194.54 223.72
# 27301 496.19 471.38 542.09
27303 643.67 611.49 703.21
27455 957.33 909.46 1,045.88
27457 984.43 935.21 1,075.49
27606 301.74 286.65 329.65
27607 621.70 590.62 679.21
27305 470.01 446.51 513.49
27306 382.08 362.98 417.43
27465 1,234.34 1,172.62 1,348.51
27466 1,202.25 1,142.14 1,313.46
27610 664.29 631.08 725.74
27612 578.71 549.77 632.24
27307 469.03 445.58 512.42
27310 733.09 696.44 800.91
27468 1,359.26 1,291.30 1,485.00
27470 1,199.47 1,139.50 1,310.43
27613 253.70 241.02 277.17
# 27613 168.43 160.01 184.01
27323 270.48 256.96 295.50 27472 1,295.50 1,230.73 1,415.34 27614 566.60 538.27 619.01
# 27323 179.47 170.50 196.08
27324 383.00 363.85 418.43
27475 662.18 629.07 723.43
27477 741.61 704.53 810.21
# 27614 415.50 394.73 453.94
27615 889.18 844.72 971.43
27325 529.32 502.85 578.28
27326 489.55 465.07 534.83
27479 954.43 906.71 1,042.72
27485 677.72 643.83 740.40
27618 493.53 468.85 539.18
# 27618 386.17 366.86 421.89
27327 454.24 431.53 496.26 27486 1,435.88 1,364.09 1,568.70 27619 785.47 746.20 858.13
# 27327 349.97 332.47 382.34
27328 421.37 400.30 460.35
27487 1,808.61 1,718.18 1,975.91
27488 1,216.38 1,155.56 1,328.89
# 27619 595.49 565.72 650.58
27620 469.18 445.72 512.58
27329 1,041.62 989.54 1,137.97
27330 402.51 382.38 439.74
27495 1,152.78 1,095.14 1,259.41
27496 505.41 480.14 552.16
27625 603.65 573.47 659.49
27626 652.23 619.62 712.56
27331 475.78 451.99 519.79
27332 643.98 611.78 703.55
27497 546.01 518.71 596.52
27498 594.29 564.58 649.27
27630 545.52 518.24 595.98
# 27630 377.63 358.75 412.56
27333 584.12 554.91 638.15 27499 660.36 627.34 721.44 27635 602.71 572.57 658.46
27334 684.32 650.10 747.62
27335 773.26 734.60 844.79
# 27500 474.36 450.64 518.24
27500 512.36 486.74 559.75
27637 763.54 725.36 834.16
27638 794.01 754.31 867.46
27340 366.14 347.83 400.00
27345 481.94 457.84 526.52
27501 502.07 476.97 548.52
# 27501 494.56 469.83 540.30
27640 879.35 835.38 960.69
27641 704.55 669.32 769.72
27347 515.81 490.02 563.52 27502 794.67 754.94 868.18 27645 1,066.03 1,012.73 1,164.64
27350 654.89 622.15 715.47
27355 607.11 576.75 663.26
27503 810.84 770.30 885.85
27506 1,351.44 1,283.87 1,476.45
27646 941.86 894.77 1,028.99
27647 825.53 784.25 901.89
27356 742.93 705.78 811.65
27357 824.04 782.84 900.27
27507 1,001.31 951.24 1,093.93
27508 517.96 492.06 565.87
27648 170.47 161.95 186.24
# 27648 53.83 51.14 58.81
27358 295.92 281.12 323.29
27360 858.64 815.71 938.07
# 27508 487.03 462.68 532.08
27509 650.12 617.61 710.25
27650 688.87 654.43 752.59
27652 753.77 716.08 823.49
27365 1,242.59 1,180.46 1,357.53 27510 703.82 668.63 768.92 27654 736.37 699.55 804.48
27370 177.09 168.24 193.48
# 27370 54.27 51.56 59.29
27511 1,036.65 984.82 1,132.54
27513 1,302.20 1,237.09 1,422.65
27656 550.45 522.93 601.37
# 27656 356.50 338.68 389.48
27372 604.06 573.86 659.94
# 27372 405.69 385.41 443.22
27514 1,052.12 999.51 1,149.44
27516 486.13 461.82 531.09
27658 391.14 371.58 427.32
27659 511.42 485.85 558.73
27380 596.95 567.10 652.17 # 27516 456.97 434.12 499.24 27664 373.86 355.17 408.45
27381 810.43 769.91 885.40
27385 638.47 606.55 697.53
27517 677.39 643.52 740.05
27519 951.27 903.71 1,039.27
27665 427.41 406.04 466.95
27675 520.51 494.48 568.65
27386 840.78 798.74 918.55
27390 442.55 420.42 483.48
27520 309.64 294.16 338.28
# 27520 278.71 264.77 304.49
27676 632.94 601.29 691.48
27680 442.73 420.59 483.68
27391 575.19 546.43 628.39
27392 706.55 671.22 771.90
27524 763.85 725.66 834.51
27530 387.04 367.69 422.84
27681 527.19 500.83 575.95
27685 641.95 609.85 701.33
27393 510.10 484.60 557.29 # 27530 358.77 340.83 391.95 # 27685 487.31 462.94 532.38
27394 657.91 625.01 718.76
27395 889.29 844.83 971.55
27532 612.84 582.20 669.53
# 27532 577.94 549.04 631.40
27686 575.08 546.33 628.28
27687 473.19 449.53 516.96
27396 619.07 588.12 676.34
27397 908.35 862.93 992.37
27535 925.87 879.58 1,011.52
27536 1,205.11 1,144.85 1,316.58
27690 649.78 617.29 709.88
27691 764.00 725.80 834.67
27400 688.19 653.78 751.85 27538 462.04 438.94 504.78 27692 114.39 108.67 124.97
27403 647.56 615.18 707.46
27405 682.39 648.27 745.51
# 27538 431.56 409.98 471.48
27540 845.64 803.36 923.86
27695 504.59 479.36 551.26
27696 598.63 568.70 654.01
27407 776.54 737.71 848.37
27409 976.35 927.53 1,066.66
27550 484.74 460.50 529.58
# 27550 449.40 426.93 490.97
27698 672.42 638.80 734.62
27700 632.25 600.64 690.74
27412 1,684.96 1,600.71 1,840.82
27415 1,415.09 1,344.34 1,545.99
27552 624.95 593.70 682.76
27556 935.58 888.80 1,022.12
27702 1,016.49 965.67 1,110.52
27703 1,174.62 1,115.89 1,283.27
27416 975.96 927.16 1,066.23 27557 1,117.29 1,061.43 1,220.64 27704 578.27 549.36 631.76
27418 843.83 801.64 921.89
27420 756.20 718.39 826.15
27558 1,250.20 1,187.69 1,365.84
27560 357.42 339.55 390.48
27705 781.34 742.27 853.61
27707 401.94 381.84 439.12
CODES: 27253 - 27707
# - These amounts apply when the service is performed in a facility setting.
C - The payment for the technical component is capped at the OPPS amount.
Limiting charge applies to unassigned claims by non-participating providers. All CPT codes and modifiers are bolded.
All Current Procedural Terminology (CPT) codes and descriptors are copyrighted 2008 by the American Medical Association..

27709
27712
27715
27720
27722
27724
27725
27726
27727
27730
27732
27734
27740
27742
27745
27750
27750
27752
27752
27756
27758
27759
27760
27760
27762
27762
27766
27767
27767
27768
27769
27780
27780
27781
27781
27784
27786
27786
27788
27788
27792
27808
27808
27810
27810
27814
27816
27816
27818
27818
27822
27823
27824
27824
27825
27825
27826
27827
27828
27829
27830
27830
27831
27832
27840
27842
27846
27848
27860
27870
27871
27880
27881
27882
27884
27886
27888
27889
27892
27893
27894
28001
28001
28002
28002
28003
28003
28005
28008
28008
28010
28010
28011
28011
28020
28020
28022
28022
28024
28024
28035
28035
28043
28043
28045
28045
28046
28046
28050
28050
28052
28052
28054
28054
28055
28060
28060
28062
28062
28070
28070
28072
28072
28080
28080
28086
28086
28088
28088
28090
28090
28092
28092
28100
28100
28102
28103
28104
28104
28106
28107
28107
28108
28108
28110
28110
28111
28111
28112
28112
28113
28113
28114
28114
28116
28116
28118
28118
28119
28119
28120
28120
28122
28122
28124
28124
28126
28126
28130
28140
28140
28150
28150
28153
28153
28160
28160
28171
28173
28173
28175
28175
28190
28190
28192
28192
28193
28193
28200
28200
28202
28202
28208
28208
28210
28210
28220
28220
28222
28222
28225
28225
28226
28226
28230
28230
28232
28232
28234
28234
28238
28238
28240
28240
28250
28250
28260
28260
28261
28261
28262
28262
28264
28264
28270
28270
28272
28272
28280
28280
28285






California - MEDICARE CARRIER 01192 FSY2009 LOCALITY 18 FEE SCHEDULE PAGE: 11
PROCEDURE PAR NONPAR LIMITING
CODE/MOD FEE FEE CHARGE
PROCEDURE
CODE/MOD
PAR
FEE
NONPAR
FEE
LIMITING
CHARGE
PROCEDURE
CODE/MOD
PAR
FEE
NONPAR LIMITING
FEE CHARGE
27709 1,130.19 1,073.68 1,234.73
27712 1,111.79 1,056.20 1,214.63
27715 1,085.26 1,031.00 1,185.65
27720 894.68 849.95 977.44
27722 891.72 847.13 974.20
27724 1,306.43 1,241.11 1,427.28
27725 1,219.82 1,158.83 1,332.65
27726 922.32 876.20 1,007.63
27727 985.03 935.78 1,076.15
27730 598.90 568.96 654.30
27732 405.53 385.25 443.04
27734 603.80 573.61 659.65
27740 671.46 637.89 733.57
27742 703.62 668.44 768.71
27745 768.21 729.80 839.27
27750 334.07 317.37 364.98
# 27750 304.91 289.66 333.11
27752 532.79 506.15 582.07
# 27752 494.80 470.06 540.57
27756 573.78 545.09 626.85
27758 901.14 856.08 984.49
27759 1,019.68 968.70 1,114.01
27760 322.12 306.01 351.91
# 27760 290.75 276.21 317.64
27762 477.93 454.03 522.13
# 27762 439.49 417.52 480.15
27766 618.72 587.78 675.95
27767 255.43 242.66 279.06
# 27767 256.76 243.92 280.51
27768 405.48 385.21 442.99
27769 697.61 662.73 762.14
27780 288.53 274.10 315.22
# 27780 259.81 246.82 283.84
27781 414.76 394.02 453.12
# 27781 385.16 365.90 420.79
27784 697.13 662.27 761.61
27786 305.51 290.23 333.76
# 27786 273.25 259.59 298.53
27788 418.26 397.35 456.95
# 27788 383.79 364.60 419.29
27792 705.22 669.96 770.45
27808 320.53 304.50 350.18
# 27808 286.07 271.77 312.54
27810 467.76 444.37 511.03
# 27810 428.43 407.01 468.06
27814 788.63 749.20 861.58
27816 302.10 287.00 330.05
# 27816 270.29 256.78 295.30
27818 480.76 456.72 525.23
# 27818 436.14 414.33 476.48
27822 866.55 823.22 946.70
27823 984.53 935.30 1,075.60
27824 301.97 286.87 329.90
# 27824 290.04 275.54 316.87
27825 546.00 518.70 596.51
# 27825 499.17 474.21 545.34
27826 829.05 787.60 905.74
27827 1,105.62 1,050.34 1,207.89
27828 1,316.93 1,251.08 1,438.74
27829 662.98 629.83 724.30
27830 350.19 332.68 382.58
# 27830 326.77 310.43 356.99
27831 379.75 360.76 414.87
27832 708.78 673.34 774.34
27840 347.42 330.05 379.56
27842 487.50 463.13 532.60
27846 751.36 713.79 820.86
27848 850.21 807.70 928.86
27860 182.09 172.99 198.94
27870 1,067.91 1,014.51 1,166.69
27871 705.08 669.83 770.30
27880 931.61 885.03 1,017.78
27881 907.73 862.34 991.69
27882 637.73 605.84 696.72
27884 595.26 565.50 650.33
27886 678.84 644.90 741.64
27888 719.47 683.50 786.03
27889
27892
27893
27894
28001
# 28001
28002
# 28002
28003
# 28003
28005
28008
# 28008
28010
# 28010
28011
# 28011
28020
# 28020
28022
# 28022
28024
# 28024
28035
# 28035
28043
# 28043
28045
# 28045
28046
# 28046
28050
# 28050
28052
# 28052
28054
# 28054
28055
28060
# 28060
28062
# 28062
28070
# 28070
28072
# 28072
28080
# 28080
28086
# 28086
28088
# 28088
# 28090
28090
28092
# 28092
28100
# 28100
28102
28103
28104
# 28104
28106
28107
# 28107
28108
# 28108
28110
# 28110
28111
# 28111
28112
# 28112
28113
# 28113
28114
# 28114
697.54
552.15
559.93
856.57
274.52
187.04
507.30
394.64
692.36
578.37
633.32
432.46
317.59
237.79
221.45
336.13
311.39
515.27
374.33
475.30
346.29
452.21
328.50
518.13
377.64
344.36
271.90
484.54
344.04
869.40
697.98
456.75
326.41
421.05
296.46
397.09
271.17
410.20
509.19
378.41
596.73
441.22
505.68
370.49
501.50
361.00
491.30
364.94
539.16
377.02
458.81
314.77
326.83
459.81
417.40
288.39
593.32
424.98
579.95
466.64
507.33
370.81
490.89
563.82
404.77
427.92
306.42
451.27
306.36
511.17
356.53
485.49
334.83
577.47
437.85
1,043.49
845.11
662.66
524.54
531.93
813.74
260.79
177.69
481.94
374.91
657.74
549.45
601.65
410.84
301.71
225.90
210.38
319.32
295.82
489.51
355.61
451.54
328.98
429.60
312.08
492.22
358.76
327.14
258.31
460.31
326.84
825.93
663.08
433.91
310.09
400.00
281.64
377.24
257.61
389.69
483.73
359.49
566.89
419.16
480.40
351.97
476.43
342.95
466.74
346.69
512.20
358.17
435.87
299.03
310.49
436.82
396.53
273.97
563.65
403.73
550.95
443.31
481.96
352.27
466.35
535.63
384.53
406.52
291.10
428.71
291.04
485.61
338.70
461.22
318.09
548.60
415.96
991.32
802.85
762.06
603.22
611.72
935.80
299.91
204.34
554.23
431.15
756.40
631.87
691.90
472.47
346.97
259.79
241.94
367.22
340.19
562.94
408.95
519.27
378.33
494.04
358.89
566.05
412.57
376.21
297.06
529.36
375.87
949.82
762.54
499.00
356.60
460.00
323.89
433.83
296.25
448.14
556.29
413.41
651.92
482.03
552.46
404.77
547.89
394.39
536.75
398.69
589.03
411.90
501.25
343.88
357.06
502.34
456.01
315.07
648.20
464.29
633.59
509.81
554.25
405.11
536.30
615.97
442.21
467.50
334.77
493.02
334.70
558.45
389.51
530.40
365.80
630.89
478.35
1,140.02
923.28
28116
# 28116
28118
# 28118
28119
# 28119
28120
# 28120
28122
# 28122
28124
# 28124
28126
# 28126
28130
28140
# 28140
28150
# 28150
28153
# 28153
28160
# 28160
28171
28173
# 28173
28175
# 28175
28190
# 28190
28192
# 28192
28193
# 28193
28200
# 28200
28202
# 28202
28208
# 28208
28210
# 28210
28220
# 28220
28222
# 28222
28225
# 28225
28226
# 28226
28230
# 28230
28232
# 28232
28234
# 28234
28238
# 28238
28240
# 28240
28250
# 28250
28260
# 28260
28261
# 28261
28262
# 28262
28264
# 28264
28270
# 28270
28272
# 28272
28280
# 28280
28285
741.51
594.83
580.86
433.73
516.96
382.65
576.49
413.46
663.50
528.31
474.10
353.93
385.73
266.88
657.43
625.08
479.72
428.83
304.23
400.78
277.07
411.43
289.49
639.02
740.30
582.57
546.19
412.32
247.73
140.81
469.91
337.81
536.34
400.26
470.18
337.19
619.95
467.52
453.16
324.15
578.28
437.35
446.06
326.33
513.00
387.08
389.51
271.11
467.12
338.55
429.36
310.95
383.21
265.69
398.23
279.39
678.48
524.73
441.81
318.98
559.40
422.44
678.39
542.75
975.59
822.28
1,371.02
1,159.83
879.62
730.28
477.29
353.58
390.79
275.04
524.08
384.47
462.53
704.43 810.09
565.09 649.85
551.82 634.59
412.04 473.85
491.11 564.78
363.52 418.05
547.67 629.82
392.79 451.71
630.33 724.88
501.89 577.17
450.40 517.96
336.23 386.66
366.44 421.41
253.54 291.57
624.56 718.24
593.83 682.90
455.73 524.09
407.39 468.50
289.02 332.37
380.74 437.85
263.22 302.70
390.86 449.49
275.02 316.27
607.07 698.13
703.29 808.78
553.44 636.46
518.88 596.71
391.70 450.46
235.34 270.64
133.77 153.84
446.41 513.37
320.92 369.06
509.52 585.95
380.25 437.29
446.67 513.67
320.33 368.38
588.95 677.29
444.14 510.76
430.50 495.08
307.94 354.13
549.37 631.78
415.48 477.80
423.76 487.32
310.01 356.51
487.35 560.45
367.73 422.89
370.03 425.53
257.55 296.18
443.76 510.32
321.62 369.86
407.89 469.07
295.40 339.71
364.05 418.66
252.41 290.27
378.32 435.07
265.42 305.23
644.56 741.24
498.49 573.26
419.72 482.68
303.03 348.48
531.43 611.14
401.32 461.52
644.47 741.14
515.61 592.95
926.81 1,065.83
781.17 898.35
1,302.47 1,497.84
1,101.84 1,267.12
835.64 960.99
693.77 797.84
453.43 521.44
335.90 386.29
371.25 426.94
261.29 300.48
497.88 572.56
365.25 420.04
439.40 505.31
CODES: 27709 - 28285
# - These amounts apply when the service is performed in a facility setting.
C - The payment for the technical component is capped at the OPPS amount.
Limiting charge applies to unassigned claims by non-participating providers. All CPT codes and modifiers are bolded.
All Current Procedural Terminology (CPT) codes and descriptors are copyrighted 2008 by the American Medical Association.

28285
28286
28286
28288
28288
28289
28289
28290
28290
28292
28292
28293
28293
28294
28294
28296
28296
28297
28297
28298
28298
28299
28299
28300
28302
28304
28304
28305
28306
28306
28307
28307
28308
28308
28309
28310
28310
28312
28312
28313
28313
28315
28315
28320
28322
28322
28340
28340
28341
28341
28344
28344
28345
28345
28360
28400
28400
28405
28405
28406
28415
28420
28430
28430
28435
28435
28436
28445
28446
28450
28450
28455
28455
28456
28465
28470
28470
28475
28475
28476
28485
28490
28490
28495
28495
28496
28496
28505
28505
28510
28510
28515
28515
28525
28525
28530
28530
28531
28531
28540
28540
28545
28545
28546
28546
28555
28555
28570
28570
28575
28575
28576
28585
28585
28600
28600
28605
28605
28606
28615
28630
28630
28635
28635
28636
28636
28645
28645
28660
28660
28665
28665
28666
28675
28675
28705
28715
28725
28730
28735
28737
28740
28740
28750
28750
28755
28755
28760
28760
28800
28805
28810
28820
28820
28825
28825
28890
28890
29000
29000
29010
29010
29015
29015
29020
29020
29025
29025
29035
29035
29040
29040
29044
29044
29046
29046
29049
29049
29055
29055
29058
29058
29065
29065
29075
29075
29085
29085
29086
29086
29105
29105
29125
29125
29126
29126
29130
29130
29131
29131
29200
29200
29220
29220
29240
29240
29260
29260
29280
29280
29305
29305
29325
29325
29345
29345
29355
29355
29358
29358
29365
29365
29405
29405
29425
29425
29435
29435
29440
29440
29445






California - MEDICARE CARRIER 01192 FSY2009 LOCALITY 18 FEE SCHEDULE PAGE: 12
PROCEDURE PAR NONPAR CHARGE
CODE/MOD FEE FEE LIMIT
PROCEDURE PAR NONPAR CHARGE
CODE/MOD FEE FEE LIMIT
PROCEDURE PAR NONPAR CHARGE
CODE/MOD FEE FEE LIMIT
# 28285 339.26 322.30 370.65
28286 451.61 429.03 493.38
28475 263.44 250.27 287.81
# 28475 242.23 230.12 264.64
28825 573.90 545.21 626.99
# 28825 408.66 388.23 446.46
# 28286 324.81 308.57 354.86 28476 345.71 328.42 377.68 28890 349.67 332.19 382.02
28288 579.39 550.42 632.98
# 28288 443.76 421.57 484.81
28485 540.84 513.80 590.87
28490 136.24 129.43 148.84
# 28890 233.47 221.80 255.07
29000 272.21 258.60 297.39
28289 727.29 690.93 794.57
# 28289 573.09 544.44 626.11
# 28490 118.57 112.64 129.54
28495 170.89 162.35 186.70
# 29000 174.13 165.42 190.23
29010 248.12 235.71 271.07
28290 571.22 542.66 624.06 # 28495 150.57 143.04 164.50 # 29010 160.64 152.61 175.50
# 28290 420.57 399.54 459.47
28292 772.18 733.57 843.61
28496 425.35 404.08 464.69
# 28496 231.39 219.82 252.79
29015 238.22 226.31 260.26
# 29015 162.67 154.54 177.72
# 28292 617.11 586.25 674.19
28293 1,034.04 982.34 1,129.69
28505 655.39 622.62 716.01
# 28505 492.80 468.16 538.38
29020 229.16 217.70 250.36
# 29020 146.54 139.21 160.09
# 28293 742.89 705.75 811.61
28294 744.86 707.62 813.76
28510 117.24 111.38 128.09
# 28510 115.03 109.28 125.67
29025 260.15 247.14 284.21
# 29025 179.74 170.75 196.36
# 28294 565.49 537.22 617.80 28515 154.32 146.60 168.59 29035 243.79 231.60 266.34
28296 732.77 696.13 800.55
# 28296 565.32 537.05 617.61
# 28515 141.51 134.43 154.59
28525 556.31 528.49 607.76
# 29035 143.06 135.91 156.30
29040 232.08 220.48 253.55
28297 826.99 785.64 903.49
# 28297 633.92 602.22 692.55
# 28525 394.17 374.46 430.63
28530 113.09 107.44 123.56
# 29040 158.29 150.38 172.94
29044 262.94 249.79 287.26
28298 714.24 678.53 780.31 # 28530 104.25 99.04 113.90 # 29044 166.18 157.87 181.55
# 28298 539.28 512.32 589.17
28299 910.07 864.57 994.26
28531 373.16 354.50 407.68
# 28531 196.88 187.04 215.10
29046 286.46 272.14 312.96
# 29046 190.58 181.05 208.21
# 28299 725.83 689.54 792.97
28300 687.35 652.98 750.93
28540 199.49 189.52 217.95
# 28540 185.79 176.50 202.98
29049 85.78 81.49 93.71
# 29049 61.48 58.41 67.17
28302 680.26 646.25 743.19
28304 790.77 751.23 863.91
28545 245.91 233.61 268.65
# 28545 225.58 214.30 246.45
29055 207.63 197.25 226.84
# 29055 136.94 130.09 149.60
# 28304 621.99 590.89 679.52 28546 473.57 449.89 517.37 29058 109.78 104.29 119.93
28305 715.60 679.82 781.79
28306 599.70 569.72 655.18
# 28546 305.23 289.97 333.47
28555 857.44 814.57 936.76
# 29058 83.27 79.11 90.98
29065 94.01 89.31 102.71
# 28306 423.86 402.67 463.07
28307 710.92 675.37 776.68
# 28555 664.36 631.14 725.81
28570 173.00 164.35 189.00
# 29065 68.82 65.38 75.19
29075 87.46 83.09 95.55
# 28307 479.85 455.86 524.24 # 28570 154.88 147.14 169.21 # 29075 62.28 59.17 68.05
28308 543.18 516.02 593.42
# 28308 388.99 369.54 424.97
28575 330.47 313.95 361.04
# 28575 307.94 292.54 336.42
29085 92.83 88.19 101.42
# 29085 66.77 63.43 72.94
28309 920.68 874.65 1,005.85
28310 533.55 506.87 582.90
28576 357.87 339.98 390.98
28585 909.26 863.80 993.37
29086 71.26 67.70 77.86
# 29086 49.17 46.71 53.72
# 28310 377.59 358.71 412.52
28312 491.41 466.84 536.87
# 28585 745.35 708.08 814.29
28600 209.68 199.20 229.08
29105 85.63 81.35 93.55
# 29105 59.56 56.58 65.07
# 28312 338.54 321.61 369.85 # 28600 187.59 178.21 204.94 29125 67.04 63.69 73.24
28313 514.68 488.95 562.29
# 28313 389.20 369.74 425.20
28605 269.29 255.83 294.20
# 28605 250.73 238.19 273.92
# 29125 42.74 40.60 46.69
29126 76.45 72.63 83.52
28315 470.80 447.26 514.35
# 28315 344.44 327.22 376.30
28606 395.94 376.14 432.56
28615 790.06 750.56 863.14
# 29126 52.15 49.54 56.97
29130 39.95 37.95 43.64
28320 648.99 616.54 709.02 28630 147.25 139.89 160.87 # 29130 28.91 27.46 31.58
28322 772.75 734.11 844.23
# 28322 600.00 570.00 655.50
# 28630 111.47 105.90 121.79
28635 176.76 167.92 193.11
29131 49.80 47.31 54.41
# 29131 32.57 30.94 35.58
28340 613.41 582.74 670.15
# 28340 464.52 441.29 507.48
# 28635 140.97 133.92 154.01
28636 294.08 279.38 321.29
29200 52.96 50.31 57.86
# 29200 40.59 38.56 44.34
28341 703.42 668.25 768.49
# 28341 547.90 520.51 598.59
# 28636 209.69 199.21 229.09
28645 617.69 586.81 674.83
29220 54.79 52.05 59.86
# 29220 42.42 40.30 46.35
28344 478.37 454.45 522.62 # 28645 479.84 455.85 524.23 29240 59.32 56.35 64.80
# 28344 330.36 313.84 360.92
28345 572.01 543.41 624.92
28660 107.25 101.89 117.17
# 28660 85.60 81.32 93.52
# 29240 45.19 42.93 49.37
29260 51.70 49.12 56.49
# 28345 429.31 407.84 469.02
28360 995.83 946.04 1,087.95
28665 155.93 148.13 170.35
# 28665 140.02 133.02 152.97
# 29260 37.56 35.68 41.03
29280 50.06 47.56 54.69
28400 243.28 231.12 265.79 28666 200.70 190.67 219.27 # 29280 35.48 33.71 38.77
# 28400 222.51 211.38 243.09
28405 390.73 371.19 426.87
28675 570.17 541.66 622.91
# 28675 404.93 384.68 442.38
29305 234.37 222.65 256.05
# 29305 160.15 152.14 174.96
# 28405 364.66 346.43 398.39
28406 535.98 509.18 585.56
28705 1,346.03 1,278.73 1,470.54
28715 999.89 949.90 1,092.39
29325 260.41 247.39 284.50
# 29325 180.88 171.84 197.62
28415 1,166.62 1,108.29 1,274.53
28420 1,225.03 1,163.78 1,338.35
28725 822.19 781.08 898.24
28730 862.35 819.23 942.11
29345 134.19 127.48 146.60
# 29345 103.26 98.10 112.82
28430 227.18 215.82 248.19 28735 822.32 781.20 898.38 29355 138.33 131.41 151.12
# 28430 201.12 191.06 219.72
28435 318.23 302.32 347.67
28737 728.03 691.63 795.37
28740 851.17 808.61 929.90
# 29355 109.61 104.13 119.75
29358 151.95 144.35 166.00
# 28435 293.49 278.82 320.64
28436 432.26 410.65 472.25
# 28740 647.06 614.71 706.92
28750 832.14 790.53 909.11
# 29358 105.12 99.86 114.84
29365 120.79 114.75 131.96
28445 1,096.91 1,042.06 1,198.37 # 28750 617.85 586.96 675.00 # 29365 89.87 85.38 98.19
28446 1,198.62 1,138.69 1,309.49
28450 210.34 199.82 229.79
28755 502.66 477.53 549.16
# 28755 351.12 333.56 383.59
29405 88.92 84.47 97.14
# 29405 65.95 62.65 72.05
# 28450 187.37 178.00 204.70
28455 289.20 274.74 315.95
28760 780.08 741.08 852.24
# 28760 604.24 574.03 660.13
29425 95.73 90.94 104.58
# 29425 72.31 68.69 78.99
# 28455 268.87 255.43 293.74
28456 279.48 265.51 305.34
28800 588.74 559.30 643.20
28805 766.97 728.62 837.91
29435 117.70 111.82 128.59
# 29435 87.66 83.28 95.77
28465 625.35 594.08 683.19 28810 454.41 431.69 496.44 29440 52.44 49.82 57.29
28470 209.77 199.28 229.17
# 28470 188.12 178.71 205.52
28820 533.09 506.44 582.41
# 28820 360.34 342.32 393.67
# 29440 35.21 33.45 38.47
29445 145.79 138.50 159.28
CODES: 28285 - 29445
# - These amounts apply when the service is performed in a facility setting.
C - The payment for the technical component is capped at the OPPS amount.
Limiting charge applies to unassigned claims by non-participating providers. All CPT codes and modifiers are bolded.
All Current Procedural Terminology (CPT) codes and descriptors are copyrighted 2008 by the American Medical Association..

29445
29450
29450
29505
29505
29515
29515
29520
29520
29530
29530
29540
29540
29550
29550
29580
29580
29590
29590
29700
29700
29705
29705
29710
29710
29715
29715
29720
29720
29730
29730
29740
29740
29750
29750
29800
29804
29805
29806
29807
29819
29820
29821
29822
29823
29824
29825
29826
29827
29828
29830
29834
29835
29836
29837
29838
29840
29843
29844
29845
29846
29847
29848
29850
29851
29855
29856
29860
29861
29862
29863
29866
29867
29868
29870
29871
29873
29874
29875
29876
29877
29879
29880
29881
29882
29883
29884
29885
29886
29887
29888
29889
29891
29892
29893
29893
29894
29895
29897
29898
29899
29900
29901
29902
29904
29905
29906
29907
30000
30000
30020
30020
30100
30100
30110
30110
30115
30117
30117
30118
30120
30120
30124
30125
30130
30140
30150
30160
30200
30200
30210
30210
30220
30220
30300
30300
30310
30320
30400
30410
30420
30430
30435
30450
30460
30462
30465
30520
30540
30545
30560
30560
30580
30580
30600
30600
30620
30630
30801
30801
30802
30802
30901
30901
30903
30903
30905
30905
30906
30906
30915
30920
30930
31000
31000
31002
31020
31020
31030
31030
31032
31040
31050
31051
31070
31075
31080
31081
31084
31085
31086
31087
31090
31200
31201
31205
31225
31230
31231
31231
31233
31233
31235
31235
31237
31237
31238
31238
31239
31240
31254
31255
31256
31267
31276
31287
31288
31290
31291
31292
31293
31294
31300
31320
31360
31365
31367
31368
31370
31375
31380






California - MEDICARE CARRIER 01192 FSY2009 LOCALITY 18 FEE SCHEDULE PAGE: 13
PROCEDURE PAR NONPAR LIMITING
CODE/MOD FEE FEE CHARGE
PROCEDURE
CODE/MOD
PAR
FEE
NONPAR
FEE
LIMITING
CHARGE
PROCEDURE
CODE/MOD
PAR
FEE
NONPAR LIMITING
FEE CHARGE
# 29445 114.87 109.13 125.50
29450 152.64 145.01 166.76
# 29450 127.01 120.66 138.76
29505 75.94 72.14 82.96
# 29505 48.11 45.70 52.56
29515 70.66 67.13 77.20
# 29515 50.34 47.82 54.99
29520 50.30 47.79 54.96
# 29520 37.49 35.62 40.96
29530 52.45 49.83 57.30
# 29530 38.31 36.39 41.85
29540 42.98 40.83 46.95
# 29540 34.14 32.43 37.29
29550 41.92 39.82 45.79
# 29550 32.20 30.59 35.18
29580 53.17 50.51 58.09
# 29580 37.70 35.82 41.19
29590 55.89 53.10 61.07
# 29590 43.07 40.92 47.06
29700 64.81 61.57 70.81
# 29700 35.65 33.87 38.95
29705 67.21 63.85 73.43
# 29705 49.09 46.64 53.64
29710 117.52 111.64 128.39
# 29710 83.94 79.74 91.70
29715 90.04 85.54 98.37
# 29715 57.34 54.47 62.64
29720 80.26 76.25 87.69
# 29720 45.36 43.09 49.55
29730 65.22 61.96 71.25
# 29730 47.10 44.75 51.46
29740 93.22 88.56 101.84
# 29740 68.48 65.06 74.82
# 29750 78.58 74.65 85.85
29750 101.55 96.47 110.94
29800 523.94 497.74 572.40
29804 648.03 615.63 707.97
29805 475.27 451.51 519.24
29806 1,079.59 1,025.61 1,179.45
29807 1,052.11 999.50 1,149.43
29819 594.37 564.65 649.35
29820 548.35 520.93 599.07
29821 598.85 568.91 654.25
29822 582.10 553.00 635.95
29823 636.56 604.73 695.44
29824 678.06 644.16 740.78
29825 593.48 563.81 648.38
29826 679.42 645.45 742.27
29827 1,106.01 1,050.71 1,208.32
29828 924.79 878.55 1,010.33
29830 458.10 435.20 500.48
29834 499.17 474.21 545.34
29835 512.10 486.50 559.48
29836 587.95 558.55 642.33
29837 536.44 509.62 586.06
29838 599.37 569.40 654.81
29840 449.84 427.35 491.45
29843 483.06 458.91 527.75
29844 500.94 475.89 547.27
29845 570.44 541.92 623.21
29846 526.68 500.35 575.40
29847 546.43 519.11 596.98
29848 499.57 474.59 545.78
29850 574.88 546.14 628.06
29851 950.24 902.73 1,038.14
29855 798.01 758.11 871.83
29856 1,017.69 966.81 1,111.83
29860 656.24 623.43 716.94
29861 727.19 690.83 794.45
29862 813.18 772.52 888.40
29863 803.85 763.66 878.21
29866 1,059.48 1,006.51 1,157.49
29867 1,279.96 1,215.96 1,398.35
29868 1,708.19 1,622.78 1,866.20
29870 412.67 392.04 450.85
29871 517.67 491.79 565.56
29873 520.36 494.34 568.49
29874
29875
29876
29877
29879
29880
29881
29882
29883
29884
29885
29886
29887
29888
29889
29891
29892
29893
# 29893
29894
29895
29897
29898
29899
29900
29901
29902
29904
29905
29906
29907
30000
# 30000
30020
# 30020
30100
# 30100
30110
# 30110
30115
30117
# 30117
30118
30120
# 30120
30124
30125
30130
30140
30150
30160
30200
# 30200
30210
# 30210
30220
# 30220
30300
# 30300
30310
30320
30400
30410
30420
30430
30435
30450
30460
30462
30465
30520
30540
30545
30560
# 30560
30580
# 30580
541.76
501.02
656.07
621.46
664.25
693.12
646.54
699.18
853.27
619.53
750.66
633.59
746.29
1,008.86
1,233.34
703.36
716.31
599.11
441.38
526.83
509.46
534.68
595.63
1,070.39
462.35
505.74
539.93
624.01
672.64
708.67
865.72
236.41
118.89
228.46
119.77
143.36
71.78
229.92
132.28
438.33
863.75
341.08
778.85
526.81
456.12
274.92
625.19
385.32
443.01
801.56
802.94
114.53
61.51
149.95
100.90
299.31
127.00
233.42
124.74
209.32
460.42
1,060.07
1,248.62
1,395.34
935.75
1,222.09
1,603.88
770.44
1,552.76
992.90
611.61
681.57
984.14
276.28
141.53
639.25
504.94
514.67
475.97
623.27
590.39
631.04
658.46
614.21
664.22
810.61
588.55
713.13
601.91
708.98
958.42
1,171.67
668.19
680.49
569.15
419.31
500.49
483.99
507.95
565.85
1,016.87
439.23
480.45
512.93
592.81
639.01
673.24
822.43
224.59
112.95
217.04
113.78
136.19
68.19
218.42
125.67
416.41
820.56
324.03
739.91
500.47
433.31
261.17
593.93
366.05
420.86
761.48
762.79
108.80
58.43
142.45
95.86
284.34
120.65
221.75
118.50
198.85
437.40
1,007.07
1,186.19
1,325.57
888.96
1,160.99
1,523.69
731.92
1,475.12
943.26
581.03
647.49
934.93
262.47
134.45
607.29
479.69
591.87
547.37
716.76
678.95
725.70
757.23
706.34
763.85
932.20
676.83
820.10
692.20
815.33
1,102.18
1,347.42
768.42
782.56
654.52
482.21
575.56
556.59
584.14
650.73
1,169.40
505.11
552.52
589.87
681.73
734.86
774.23
945.79
258.28
129.89
249.60
130.85
156.62
78.42
251.18
144.52
478.87
943.64
372.63
850.90
575.54
498.31
300.35
683.02
420.96
483.99
875.70
877.21
125.12
67.19
163.82
110.24
326.99
138.75
255.01
136.28
228.68
503.01
1,158.13
1,364.12
1,524.41
1,022.30
1,335.14
1,752.24
841.71
1,696.39
1,084.75
668.18
744.61
1,075.17
301.84
154.62
698.38
551.64
30600
# 30600
30620
30630
30801
# 30801
30802
# 30802
30901
# 30901
30903
# 30903
30905
# 30905
30906
# 30906
30915
30920
30930
31000
# 31000
31002
31020
# 31020
31030
# 31030
31032
31040
31050
31051
31070
31075
31080
31081
31084
31085
31086
31087
31090
31200
31201
31205
31225
31230
31231
# 31231
31233
# 31233
31235
# 31235
31237
# 31237
31238
# 31238
31239
31240
31254
31255
31256
31267
31276
31287
31288
31290
31291
31292
31293
31294
31300
31320
31360
31365
31367
31368
31370
31375
31380
589.28
447.46
630.33
633.21
232.06
136.18
295.89
191.18
105.61
62.76
198.11
81.91
246.34
105.40
282.02
138.43
583.43
837.17
124.00
183.06
106.62
205.82
497.10
361.02
713.54
531.07
579.41
756.83
502.96
655.72
444.05
796.17
1,025.62
1,261.82
1,197.12
1,266.96
1,131.73
1,118.84
1,019.39
548.06
743.71
868.92
1,846.00
2,063.19
198.55
79.70
275.42
142.43
315.64
169.84
339.15
188.93
348.04
204.89
673.79
168.13
286.67
422.61
208.20
334.12
532.21
244.27
283.00
1,182.30
1,246.26
1,024.68
1,115.26
1,278.62
1,281.63
668.81
2,016.19
2,513.54
2,190.71
2,447.04
2,068.96
1,957.03
1,929.53
559.82 643.79
425.09 488.85
598.81 688.63
601.55 691.78
220.46 253.53
129.37 148.78
281.10 323.27
181.62 208.86
100.33 115.38
59.62 68.56
188.20 216.43
77.81 89.48
234.02 269.12
100.13 115.15
267.92 308.11
131.51 151.24
554.26 637.40
795.31 914.61
117.80 135.47
173.91 200.00
101.29 116.48
195.53 224.86
472.25 543.09
342.97 394.42
677.86 779.54
504.52 580.20
550.44 633.01
718.99 826.84
477.81 549.48
622.93 716.37
421.85 485.13
756.36 869.81
974.34 1,120.49
1,198.73 1,378.54
1,137.26 1,307.85
1,203.61 1,384.15
1,075.14 1,236.41
1,062.90 1,222.34
968.42 1,113.68
520.66 598.76
706.52 812.50
825.47 949.29
1,753.70 2,016.76
1,960.03 2,254.03
188.62 216.91
75.72 87.08
261.65 300.90
135.31 155.61
299.86 344.84
161.35 185.55
322.19 370.52
179.48 206.40
330.64 380.24
194.65 223.85
640.10 736.12
159.72 183.68
272.34 313.19
401.48 461.70
197.79 227.46
317.41 365.02
505.60 581.44
232.06 266.87
268.85 309.18
1,123.19 1,291.67
1,183.95 1,361.54
973.45 1,119.47
1,059.50 1,218.43
1,214.69 1,396.89
1,217.55 1,400.18
635.37 730.68
1,915.38 2,202.69
2,387.86 2,746.04
2,081.17 2,393.35
2,324.69 2,673.39
1,965.51 2,260.34
1,859.18 2,138.06
1,833.05 2,108.01
CODES: 29445 - 31380
# - These amounts apply when the service is performed in a facility setting.
C - The payment for the technical component is capped at the OPPS amount.
Limiting charge applies to unassigned claims by non-participating providers. All CPT codes and modifiers are bolded.
All Current Procedural Terminology (CPT) codes and descriptors are copyrighted 2008 by the American Medical Association.

31382
31390
31395
31400
31420
31500
31502
31505
31505
31510
31510
31511
31511
31512
31512
31513
31515
31515
31520
31525
31525
31526
31527
31528
31529
31530
31531
31535
31536
31540
31541
31545
31546
31560
31561
31570
31570
31571
31575
31575
31576
31576
31577
31577
31578
31578
31579
31579
31580
31582
31584
31587
31588
31590
31595
31600
31601
31603
31605
31610
31611
31612
31612
31613
31614
31615
31615
31620
31620
31622
31622
31623
31623
31624
31624
31625
31625
31628
31628
31629
31629
31630
31631
31632
31632
31633
31633
31635
31635
31636
31637
31638
31640
31641
31643
31645
31645
31646
31646
31656
31656
31715
31717
31717
31720
31725
31730
31730
31750
31755
31760
31766
31770
31775
31780
31781
31785
31786
31800
31805
31820
31820
31825
31825
31830
31830
32035
32036
32095
32100
32110
32120
32124
32140
32141
32150
32151
32160
32200
32201
32201
32215
32220
32225
32310
32320
32400
32400
32402
32405
32405
32420
32421
32421
32422
32422
32440
32442
32445
32480
32482
32484
32486
32488
32491
32500
32501
32503
32504
32540
32550
32550
32551
32560
32560
32601
32602
32603
32604
32605
32606
32650
32651
32652
32653
32654
32655
32656
32657
32658
32659
32660
32661
32662
32663
32664
32665
32800
32810
32815
32820
32851
32852
32853
32854
32855
32856
32900
32905
32906
32940
32960
32960
32997
32998
32998
33010
33011
33015
33020
33025
33030
33031
33050
33120
33130
33140
33141
33202
33203
33206






California - MEDICARE CARRIER 01192 FSY2009 LOCALITY 18 FEE SCHEDULE PAGE: 14
PROCEDURE PAR NONPAR CHARGE
CODE/MOD FEE FEE LIMIT
PROCEDURE PAR NONPAR CHARGE
CODE/MOD FEE FEE LIMIT
PROCEDURE PAR NONPAR CHARGE
CODE/MOD FEE FEE LIMIT
31382 2,109.33 2,003.86 2,304.44
31390 2,805.36 2,665.09 3,064.85
31628 449.21 426.75 490.76
# 31628 199.58 189.60 218.04
32422 217.37 206.50 237.48
# 32422 133.86 127.17 146.25
31395 2,985.19 2,835.93 3,261.32 31629 699.87 664.88 764.61 32440 1,653.75 1,571.06 1,806.72
31400 1,025.91 974.61 1,120.80
31420 848.92 806.47 927.44
# 31629 213.43 202.76 233.17
31630 215.06 204.31 234.96
32442 3,031.73 2,880.14 3,312.16
32445 3,448.75 3,276.31 3,767.76
31500 112.73 107.09 123.15
31502 36.46 34.64 39.84
31631 242.04 229.94 264.43
31632 80.56 76.53 88.01
32480 1,560.29 1,482.28 1,704.62
32482 1,665.25 1,581.99 1,819.29
31505 87.09 82.74 95.15 # 31632 55.38 52.61 60.50 32484 1,501.51 1,426.43 1,640.39
# 31505 50.86 48.32 55.57
31510 219.87 208.88 240.21
31633 96.61 91.78 105.55
# 31633 69.22 65.76 75.62
32486 2,378.36 2,259.44 2,598.36
32488 2,413.52 2,292.84 2,636.77
# 31510 125.33 119.06 136.92
31511 218.71 207.77 238.94
31635 381.12 362.06 416.37
# 31635 199.09 189.14 217.51
32491 1,552.71 1,475.07 1,696.33
32500 1,511.13 1,435.57 1,650.91
# 31511 133.88 127.19 146.27
31512 216.37 205.55 236.38
31636 236.26 224.45 258.12
31637 83.41 79.24 91.13
32501 260.83 247.79 284.96
32503 1,902.76 1,807.62 2,078.76
# 31512 135.07 128.32 147.57 31638 264.71 251.47 289.19 32504 2,184.86 2,075.62 2,386.96
31513 137.68 130.80 150.42
31515 217.88 206.99 238.04
31640 274.87 261.13 300.30
31641 270.64 257.11 295.68
32540 1,719.37 1,633.40 1,878.41
32550 881.83 837.74 963.40
# 31515 114.06 108.36 124.61
31520 159.35 151.38 174.09
31643 185.43 176.16 202.58
31645 332.70 316.07 363.48
# 32550 241.20 229.14 263.51
32551 185.92 176.62 203.11
31525 259.03 246.08 282.99 # 31645 168.35 159.93 183.92 32560 325.71 309.42 355.83
# 31525 165.80 157.51 181.14
31526 164.88 156.64 180.14
31646 303.23 288.07 331.28
# 31646 145.95 138.65 159.45
# 32560 117.61 111.73 128.49
32601 327.23 310.87 357.50
31527 200.56 190.53 219.11
31528 150.16 142.65 164.05
31656 353.12 335.46 385.78
# 31656 118.52 112.59 129.48
32602 354.66 336.93 387.47
32603 458.90 435.96 501.35
31529 169.30 160.84 184.97
31530 206.44 196.12 225.54
31715 58.29 55.38 63.69
31717 331.07 314.52 361.70
32604 515.30 489.54 562.97
32605 406.78 386.44 444.41
31531 222.79 211.65 243.40 # 31717 116.35 110.53 127.11 32606 492.21 467.60 537.74
31535 198.20 188.29 216.53
31536 221.22 210.16 241.68
31720 54.64 51.91 59.70
31725 97.97 93.07 107.03
32650 706.87 671.53 772.26
32651 1,104.03 1,048.83 1,206.15
31540 253.94 241.24 277.43
31541 277.63 263.75 303.31
31730 964.03 915.83 1,053.20
# 31730 151.09 143.54 165.07
32652 1,672.09 1,588.49 1,826.76
32653 1,070.22 1,016.71 1,169.22
31545 374.51 355.78 409.15 31750 1,376.59 1,307.76 1,503.92 32654 1,179.63 1,120.65 1,288.75
31546 569.52 541.04 622.20
31560 327.99 311.59 358.33
31755 1,759.07 1,671.12 1,921.79
31760 1,438.00 1,366.10 1,571.02
32655 979.96 930.96 1,070.60
32656 844.19 801.98 922.28
31561 359.28 341.32 392.52
31570 359.36 341.39 392.60
31766 1,869.31 1,775.84 2,042.22
31770 1,384.53 1,315.30 1,512.60
32657 833.82 792.13 910.95
32658 762.83 724.69 833.39
# 31570 237.86 225.97 259.87
31571 261.99 248.89 286.22
31775 1,429.74 1,358.25 1,561.99
31780 1,216.49 1,155.67 1,329.02
32659 775.03 736.28 846.72
32660 1,087.07 1,032.72 1,187.63
31575 120.79 114.75 131.96 31781 1,468.43 1,395.01 1,604.26 32661 850.21 807.70 928.86
# 31575 79.70 75.72 87.08
31576 235.75 223.96 257.55
31785 1,111.89 1,056.30 1,214.75
31786 1,547.23 1,469.87 1,690.35
32662 951.28 903.72 1,039.28
32663 1,453.25 1,380.59 1,587.68
# 31576 128.39 121.97 140.27
31577 252.14 239.53 275.46
31800 719.80 683.81 786.38
31805 857.01 814.16 936.28
32664 903.22 858.06 986.77
32665 1,256.78 1,193.94 1,373.03
# 31577 155.38 147.61 169.75 31820 440.11 418.10 480.82 32800 969.10 920.65 1,058.75
31578 293.12 278.46 320.23
# 31578 176.48 167.66 192.81
# 31820 333.64 316.96 364.50
31825 611.89 581.30 668.50
32810 939.55 892.57 1,026.46
32815 2,738.56 2,601.63 2,991.87
# 31579 146.18 138.87 159.70
31579 227.03 215.68 248.03
# 31825 490.39 465.87 535.75
31830 443.89 421.70 484.96
32820 1,398.19 1,328.28 1,527.52
32851 2,720.39 2,584.37 2,972.03
31580 1,227.12 1,165.76 1,340.62
31582 1,951.94 1,854.34 2,132.49
# 31830 347.13 329.77 379.24
32035 730.97 694.42 798.58
32852 3,016.47 2,865.65 3,295.50
32853 3,241.76 3,079.67 3,541.62
31584 1,547.78 1,470.39 1,690.95 32036 792.38 752.76 865.67 32854 3,535.66 3,358.88 3,862.71
31587 998.75 948.81 1,091.13
31588 1,150.92 1,093.37 1,257.38
32095 649.90 617.41 710.02
32100 1,000.49 950.47 1,093.04
32855 275.75 261.96 301.25
32856 331.96 315.36 362.66
31590 926.28 879.97 1,011.97
31595 786.08 746.78 858.80
32110 1,501.10 1,426.05 1,639.96
32120 898.05 853.15 981.12
32900 1,419.61 1,348.63 1,550.92
32905 1,401.61 1,331.53 1,531.26
31600 408.15 387.74 445.90 32124 953.63 905.95 1,041.84 32906 1,737.63 1,650.75 1,898.36
31601 271.97 258.37 297.13
31603 229.61 218.13 250.85
32140 1,019.21 968.25 1,113.49
32141 1,524.65 1,448.42 1,665.68
32940 1,284.33 1,220.11 1,403.13
32960 148.83 141.39 162.60
31605 188.05 178.65 205.45
31610 722.51 686.38 789.34
32150 1,026.82 975.48 1,121.80
32151 1,052.07 999.47 1,149.39
# 32960 105.53 100.25 115.29
32997 372.58 353.95 407.04
31611 548.85 521.41 599.62
31612 83.76 79.57 91.51
32160 787.06 747.71 859.87
32200 1,154.41 1,096.69 1,261.19
32998 3,237.32 3,075.45 3,536.77
# 32998 327.52 311.14 357.81
# 31612 49.30 46.84 53.87 32201 1,042.16 990.05 1,138.56 33010 132.34 125.72 144.58
31613 455.96 433.16 498.13
31614 751.02 713.47 820.49
# 32201 223.04 211.89 243.67
32215 830.48 788.96 907.30
33011 129.10 122.65 141.05
33015 569.45 540.98 622.13
31615 190.47 180.95 208.09
# 31615 132.15 125.54 144.37
32220 1,655.76 1,572.97 1,808.92
32225 1,028.58 977.15 1,123.72
33020 910.49 864.97 994.72
33025 841.11 799.05 918.91
31620 311.56 295.98 340.38 32310 950.15 902.64 1,038.04 33030 1,343.07 1,275.92 1,467.31
# 31620 73.43 69.76 80.22
31622 341.55 324.47 373.14
32320 1,654.99 1,572.24 1,808.08
32400 164.85 156.61 180.10
33031 1,496.46 1,421.64 1,634.89
33050 1,040.93 988.88 1,137.21
# 31622 152.01 144.41 166.07
31623 375.22 356.46 409.93
# 32400 95.49 90.72 104.33
32402 586.60 557.27 640.86
33120 1,638.84 1,556.90 1,790.44
33130 1,443.55 1,371.37 1,577.08
# 31623 153.43 145.76 167.62
31624 347.39 330.02 379.52
32405 108.35 102.93 118.37
# 32405 107.90 102.51 117.89
33140 1,641.45 1,559.38 1,793.29
33141 160.88 152.84 175.77
# 31624 153.87 146.18 168.11 32420 118.91 112.96 129.90 33202 822.09 780.99 898.14
31625 372.60 353.97 407.07
# 31625 179.09 170.14 195.66
32421 173.69 165.01 189.76
# 32421 82.23 78.12 89.84
33203 866.47 823.15 946.62
33206 509.12 483.66 556.21
CODES: 31382 - 33206
# - These amounts apply when the service is performed in a facility setting.
C - The payment for the technical component is capped at the OPPS amount.
Limiting charge applies to unassigned claims by non-participating providers. All CPT codes and modifiers are bolded.
All Current Procedural Terminology (CPT) codes and descriptors are copyrighted 2008 by the American Medical Association..

33207
33208
33210
33211
33212
33213
33214
33215
33216
33217
33218
33220
33222
33223
33224
33225
33226
33233
33234
33235
33236
33237
33238
33240
33241
33243
33244
33249
33250
33251
33254
33255
33256
33257
33258
33259
33261
33265
33266
33282
33284
33300
33305
33310
33315
33320
33321
33322
33330
33332
33335
33400
33401
33403
33404
33405
33406
33410
33411
33412
33413
33414
33415
33416
33417
33420
33422
33425
33426
33427
33430
33460
33463
33464
33465
33468
33470
33471
33472
33474
33475
33476
33478
33496
33500
33501
33502
33503
33504
33505
33506
33507
33508
33510
33511
33512
33513
33514
33516
33517
33518
33519
33521
33522
33523
33530
33533
33534
33535
33536
33542
33545
33548
33572
33600
33602
33606
33608
33610
33611
33612
33615
33617
33619
33641
33645
33647
33660
33665
33670
33675
33676
33677
33681
33684
33688
33690
33692
33694
33697
33702
33710
33720
33722
33724
33726
33730
33732
33735
33736
33737
33750
33755
33762
33764
33766
33767
33768
33770
33771
33774
33775
33776
33777
33778
33779
33780
33781
33786
33788
33800
33802
33803
33813
33814
33820
33822
33824
33840
33845
33851
33852
33853
33860
33861
33863
33864
33870
33875
33877
33880
33881
33883
33884
33886
33889
33891
33910
33915
33916
33917
33920
33922
33924
33925
33926
33933
33935
33944
33945
33960
33961
33967
33968
33970
33971
33973
33974
33975
33976
33977
33978
33979
33980
34001
34051
34101
34111
34151
34201
34203






California - MEDICARE CARRIER 01192 FSY2009 LOCALITY 18 FEE SCHEDULE PAGE: 15
PROCEDURE PAR NONPAR LIMITING
CODE/MOD FEE FEE CHARGE
PROCEDURE PAR NONPAR LIMITING
CODE/MOD FEE FEE CHARGE
PROCEDURE PAR NONPAR LIMITING
CODE/MOD FEE FEE CHARGE
33207 543.68 516.50 593.98
33208 585.31 556.04 639.45
33471 1,404.79 1,334.55 1,534.73
33472 1,419.57 1,348.59 1,550.88
33764 1,344.66 1,277.43 1,469.04
33766 1,491.22 1,416.66 1,629.16
33210 198.93 188.98 217.33 33474 2,150.09 2,042.59 2,348.98 33767 1,496.03 1,421.23 1,634.41
33211 199.20 189.24 217.63
33212 380.16 361.15 415.32
33475 2,435.14 2,313.38 2,660.39
33476 1,544.21 1,467.00 1,687.05
33768 453.28 430.62 495.21
33770 2,268.12 2,154.71 2,477.92
33213 433.42 411.75 473.51
33214 538.22 511.31 588.01
33478 1,667.44 1,584.07 1,821.68
33496 1,780.43 1,691.41 1,945.12
33771 2,320.09 2,204.09 2,534.70
33774 1,923.64 1,827.46 2,101.58
33215 344.54 327.31 376.41 33500 1,671.01 1,587.46 1,825.58 33775 2,001.15 1,901.09 2,186.25
33216 426.07 404.77 465.49
33217 422.28 401.17 461.35
33501 1,159.11 1,101.15 1,266.32
33502 1,344.49 1,277.27 1,468.86
33776 2,105.88 2,000.59 2,300.68
33777 2,061.24 1,958.18 2,251.91
33218 440.76 418.72 481.53
33220 444.65 422.42 485.78
33503 1,448.72 1,376.28 1,582.72
33504 1,531.12 1,454.56 1,672.74
33778 2,525.31 2,399.04 2,758.90
33779 2,406.36 2,286.04 2,628.95
33222 389.82 370.33 425.88
33223 468.79 445.35 512.15
33505 2,080.82 1,976.78 2,273.30
33506 2,170.23 2,061.72 2,370.98
33780 2,509.46 2,383.99 2,741.59
33781 2,464.69 2,341.46 2,692.68
33224 564.05 535.85 616.23 33507 1,840.42 1,748.40 2,010.66 33786 2,429.46 2,307.99 2,654.19
33225 507.39 482.02 554.32
33226 545.35 518.08 595.79
33508 17.22 16.36 18.81
33510 2,077.28 1,973.42 2,269.43
33788 1,647.55 1,565.17 1,799.95
33800 1,032.37 980.75 1,127.86
33233 274.11 260.40 299.46
33234 546.90 519.56 597.49
33511 2,265.37 2,152.10 2,474.92
33512 2,546.43 2,419.11 2,781.98
33802 1,112.94 1,057.29 1,215.88
33803 1,207.44 1,147.07 1,319.13
33235 708.57 673.14 774.11 33513 2,597.64 2,467.76 2,837.92 33813 1,383.57 1,314.39 1,511.55
33236 828.87 787.43 905.54
33237 917.57 871.69 1,002.44
33514 2,753.19 2,615.53 3,007.86
33516 2,864.26 2,721.05 3,129.21
33814 1,618.81 1,537.87 1,768.55
33820 1,039.04 987.09 1,135.15
33238 986.45 937.13 1,077.70
33240 522.05 495.95 570.34
33517 195.45 185.68 213.53
33518 422.29 401.18 461.36
33822 1,103.25 1,048.09 1,205.30
33824 1,246.26 1,183.95 1,361.54
33241 258.39 245.47 282.29
33243 1,444.76 1,372.52 1,578.40
33519 564.06 535.86 616.24
33521 683.41 649.24 746.63
33840 1,253.07 1,190.42 1,368.98
33845 1,459.46 1,386.49 1,594.46
33244 960.55 912.52 1,049.40 33522 778.67 739.74 850.70 33851 1,334.07 1,267.37 1,457.48
33249 1,013.94 963.24 1,107.73
33250 1,541.56 1,464.48 1,684.15
33523 889.05 844.60 971.29
33530 536.63 509.80 586.27
33852 1,445.65 1,373.37 1,579.38
33853 2,002.36 1,902.24 2,187.58
33251 1,706.60 1,621.27 1,864.46
33254 1,441.07 1,369.02 1,574.37
33533 2,025.28 1,924.02 2,212.62
33534 2,350.07 2,232.57 2,567.46
33860 3,302.08 3,136.98 3,607.53
33861 2,589.08 2,459.63 2,828.57
33255 1,762.56 1,674.43 1,925.59 33535 2,605.66 2,475.38 2,846.69 33863 3,303.31 3,138.14 3,608.86
33256 2,099.78 1,994.79 2,294.01
33257 610.49 579.97 666.97
33536 2,787.97 2,648.57 3,045.86
33542 2,675.32 2,541.55 2,922.78
33864 3,397.78 3,227.89 3,712.07
33870 2,701.97 2,566.87 2,951.90
33258 688.49 654.07 752.18
33259 899.73 854.74 982.95
33545 3,154.93 2,997.18 3,446.76
33548 3,110.14 2,954.63 3,397.82
33875 2,096.86 1,992.02 2,290.82
33877 3,688.59 3,504.16 4,029.78
33261 1,697.24 1,612.38 1,854.24
33265 1,437.53 1,365.65 1,570.50
33572 249.17 236.71 272.22
33600 1,812.43 1,721.81 1,980.08
33880 1,918.62 1,822.69 2,096.09
33881 1,648.03 1,565.63 1,800.47
33266 1,968.61 1,870.18 2,150.71 33602 1,723.27 1,637.11 1,882.68 33883 1,207.57 1,147.19 1,319.27
33282 366.49 348.17 400.40
33284 266.65 253.32 291.32
33606 1,880.48 1,786.46 2,054.43
33608 1,934.56 1,837.83 2,113.50
33884 437.52 415.64 477.99
33886 1,037.79 985.90 1,133.79
33300 2,407.15 2,286.79 2,629.81
33305 4,003.34 3,803.17 4,373.65
33610 1,885.25 1,790.99 2,059.64
33611 2,063.61 1,960.43 2,254.49
33889 860.20 817.19 939.77
33891 1,075.28 1,021.52 1,174.75
33310 1,231.90 1,170.31 1,345.86 33612 2,131.65 2,025.07 2,328.83 33910 1,757.27 1,669.41 1,919.82
33315 1,564.03 1,485.83 1,708.70
33320 1,116.13 1,060.32 1,219.37
33615 2,130.17 2,023.66 2,327.21
33617 2,279.90 2,165.91 2,490.80
33915 1,396.82 1,326.98 1,526.03
33916 1,770.27 1,681.76 1,934.02
33321 1,259.14 1,196.18 1,375.61
33322 1,460.52 1,387.49 1,595.61
33619 2,786.97 2,647.62 3,044.76
33641 1,693.87 1,609.18 1,850.56
33917 1,605.66 1,525.38 1,754.19
33920 1,921.50 1,825.43 2,099.24
33330 1,469.49 1,396.02 1,605.42
33332 1,472.78 1,399.14 1,609.01
33645 1,676.46 1,592.64 1,831.54
33647 1,787.04 1,697.69 1,952.34
33922 1,457.82 1,384.93 1,592.67
33924 305.01 289.76 333.22
33335 1,983.47 1,884.30 2,166.95 33660 1,863.49 1,770.32 2,035.87 33925 1,873.38 1,779.71 2,046.67
33400 2,385.52 2,266.24 2,606.18
33401 1,597.90 1,518.01 1,745.71
33665 2,013.92 1,913.22 2,200.20
33670 2,090.56 1,986.03 2,283.93
33926 2,468.48 2,345.06 2,696.82
33933 376.83 357.99 411.69
33403 1,599.65 1,519.67 1,747.62
33404 1,886.91 1,792.56 2,061.44
33675 2,091.16 1,986.60 2,284.59
33676 2,180.03 2,071.03 2,381.68
33935 3,684.82 3,500.58 4,025.67
33944 266.07 252.77 290.69
33405 2,441.09 2,319.04 2,666.90 33677 2,265.39 2,152.12 2,474.94 33945 4,850.18 4,607.67 5,298.82
33406 3,000.54 2,850.51 3,278.09
33410 2,648.54 2,516.11 2,893.53
33681 1,942.23 1,845.12 2,121.89
33684 1,971.58 1,873.00 2,153.95
33960 1,058.10 1,005.20 1,155.98
33961 588.89 559.45 643.37
33411 3,448.06 3,275.66 3,767.01
33412 2,639.39 2,507.42 2,883.53
33688 1,976.99 1,878.14 2,159.86
33690 1,224.66 1,163.43 1,337.94
33967 293.93 279.23 321.11
33968 37.55 35.67 41.02
33413 3,407.84 3,237.45 3,723.07
33414 2,282.33 2,168.21 2,493.44
33692 1,871.20 1,777.64 2,044.29
33694 2,106.34 2,001.02 2,301.17
33970 392.59 372.96 428.90
33971 762.20 724.09 832.70
33415 2,109.72 2,004.23 2,304.86 33697 2,275.94 2,162.14 2,486.46 33973 572.70 544.07 625.68
33416 2,125.91 2,019.61 2,322.55
33417 1,781.38 1,692.31 1,946.16
33702 1,624.26 1,543.05 1,774.51
33710 1,986.82 1,887.48 2,170.60
33974 972.85 924.21 1,062.84
33975 1,178.55 1,119.62 1,287.56
33420 1,431.87 1,360.28 1,564.32
33422 1,786.19 1,696.88 1,951.41
33720 1,648.65 1,566.22 1,801.15
33722 1,626.32 1,545.00 1,776.75
33976 1,312.17 1,246.56 1,433.54
33977 1,286.11 1,221.80 1,405.07
33425 2,758.55 2,620.62 3,013.71 33724 1,673.03 1,589.38 1,827.79 33978 1,412.99 1,342.34 1,543.69
33426 2,517.47 2,391.60 2,750.34
33427 2,628.93 2,497.48 2,872.10
33726 2,177.17 2,068.31 2,378.56
33730 2,068.69 1,965.26 2,260.05
33979 2,584.88 2,455.64 2,823.99
33980 3,819.75 3,628.76 4,173.07
33430 2,906.46 2,761.14 3,175.31
33460 2,452.62 2,329.99 2,679.49
33732 1,737.64 1,650.76 1,898.37
33735 1,323.22 1,257.06 1,445.62
34001 1,023.40 972.23 1,118.06
34051 1,032.99 981.34 1,128.54
33463 3,095.18 2,940.42 3,381.48
33464 2,502.94 2,377.79 2,734.46
33736 1,478.28 1,404.37 1,615.03
33737 1,380.12 1,311.11 1,507.78
34101 655.02 622.27 715.61
34111 654.73 621.99 715.29
33465 2,795.92 2,656.12 3,054.54 33750 1,395.16 1,325.40 1,524.21 34151 1,506.58 1,431.25 1,645.94
33468 1,991.77 1,892.18 2,176.01
33470 1,254.48 1,191.76 1,370.52
33755 1,370.03 1,301.53 1,496.76
33762 1,367.43 1,299.06 1,493.92
34201 1,056.41 1,003.59 1,154.13
34203 1,044.71 992.47 1,141.34
CODES: 33207 - 34203
# - These amounts apply when the service is performed in a facility setting.
C - The payment for the technical component is capped at the OPPS amount.
Limiting charge applies to unassigned claims by non-participating providers. All CPT codes and modifiers are bolded.
All Current Procedural Terminology (CPT) codes and descriptors are copyrighted 2008 by the American Medical Association.

34401
34421
34451
34471
34490
34501
34502
34510
34520
34530
34800
34802
34803
34804
34805
34806
34808
34812
34813
34820
34825
34826
34830
34831
34832
34833
34834
34900
35001
35002
35005
35011
35013
35021
35022
35045
35081
35082
35091
35092
35102
35103
35111
35112
35121
35122
35131
35132
35141
35142
35151
35152
35180
35182
35184
35188
35189
35190
35201
35206
35207
35211
35216
35221
35226
35231
35236
35241
35246
35251
35256
35261
35266
35271
35276
35281
35286
35301
35302
35303
35304
35305
35306
35311
35321
35331
35341
35351
35355
35361
35363
35371
35372
35390
35400
35450
35452
35454
35456
35458
35459
35460
35470
35470
35471
35471
35472
35472
35473
35473
35474
35474
35475
35475
35476
35476
35480
35481
35482
35483
35484
35485
35490
35491
35492
35493
35494
35495
35500
35501
35506
35508
35509
35510
35511
35512
35515
35516
35518
35521
35522
35523
35525
35526
35531
35533
35535
35536
35537
35538
35539
35540
35548
35549
35551
35556
35558
35560
35563
35565
35566
35570
35571
35572
35583
35585
35587
35600
35601
35606
35612
35616
35621
35623
35626
35631
35632
35633
35634
35636
35637
35638
35642
35645
35646
35647
35650
35651
35654
35656
35661
35663
35665
35666
35671
35681
35682
35683
35685
35686
35691
35693
35694
35695
35697
35700
35701
35721
35741
35761
35800
35820
35840
35860
35870
35875
35876
35879
35881
35883
35884
35901
35903
35905
35907
36000
36000
36002
36002
36005
36005






California - MEDICARE CARRIER 01192 FSY2009 LOCALITY 18 FEE SCHEDULE PAGE: 16
PROCEDURE PAR NONPAR CHARGE
CODE/MOD FEE FEE LIMIT
PROCEDURE PAR NONPAR CHARGE
CODE/MOD FEE FEE LIMIT
PROCEDURE PAR NONPAR CHARGE
CODE/MOD FEE FEE LIMIT
34401 1,559.95 1,481.95 1,704.24
34421 792.67 753.04 866.00
35301 1,137.92 1,081.02 1,243.17
35302 1,206.64 1,146.31 1,318.26
35551 1,618.26 1,537.35 1,767.95
35556 1,497.15 1,422.29 1,635.63
34451 1,627.78 1,546.39 1,778.35 35303 1,327.07 1,260.72 1,449.83 35558 1,330.06 1,263.56 1,453.09
34471 1,132.38 1,075.76 1,237.12
34490 659.13 626.17 720.10
35304 1,379.57 1,310.59 1,507.18
35305 1,325.31 1,259.04 1,447.90
35560 1,931.43 1,834.86 2,110.09
35563 1,480.37 1,406.35 1,617.30
34501 1,022.27 971.16 1,116.83
34502 1,649.20 1,566.74 1,801.75
35306 492.63 468.00 538.20
35311 1,627.69 1,546.31 1,778.26
35565 1,435.49 1,363.72 1,568.28
35566 1,794.40 1,704.68 1,960.38
34510 1,155.14 1,097.38 1,261.99 35321 968.32 919.90 1,057.89 35570 1,685.98 1,601.68 1,841.93
34520 1,109.03 1,053.58 1,211.62
34530 1,043.70 991.52 1,140.25
35331 1,596.13 1,516.32 1,743.77
35341 1,501.32 1,426.25 1,640.19
35571 1,456.12 1,383.31 1,590.81
35572 378.50 359.58 413.52
34800 1,239.79 1,177.80 1,354.47
34802 1,351.86 1,284.27 1,476.91
35351 1,393.67 1,323.99 1,522.59
35355 1,132.88 1,076.24 1,237.68
35583 1,545.11 1,467.85 1,688.03
35585 1,810.07 1,719.57 1,977.51
34803 1,379.93 1,310.93 1,507.57
34804 1,350.99 1,283.44 1,475.96
35361 1,716.06 1,630.26 1,874.80
35363 1,872.96 1,779.31 2,046.21
35587 1,502.30 1,427.19 1,641.27
35600 279.10 265.15 304.92
34805 1,266.51 1,203.18 1,383.66 35371 895.43 850.66 978.26 35601 1,566.13 1,487.82 1,710.99
34806 114.32 108.60 124.89
34808 224.37 213.15 245.12
35372 1,073.05 1,019.40 1,172.31
35390 174.20 165.49 190.31
35606 1,272.14 1,208.53 1,389.81
35612 1,001.68 951.60 1,094.34
34812 371.66 353.08 406.04
34813 257.59 244.71 281.42
35400 164.87 156.63 180.12
35450 558.93 530.98 610.63
35616 1,215.37 1,154.60 1,327.79
35621 1,203.05 1,142.90 1,314.34
34820 533.34 506.67 582.67 35452 388.38 368.96 424.30 35623 1,475.98 1,402.18 1,612.51
34825 761.23 723.17 831.65
34826 222.67 211.54 243.27
35454 340.87 323.83 372.40
35456 412.22 391.61 450.35
35626 1,698.91 1,613.96 1,856.05
35631 2,014.82 1,914.08 2,201.19
34830 1,974.22 1,875.51 2,156.84
34831 2,086.88 1,982.54 2,279.92
35458 528.55 502.12 577.44
35459 485.97 461.67 530.92
35632 2,068.78 1,965.34 2,260.14
35633 2,233.05 2,121.40 2,439.61
34832 2,120.18 2,014.17 2,316.30
34833 664.77 631.53 726.26
35460 337.50 320.63 368.72
35470 3,298.96 3,134.01 3,604.11
35634 2,024.96 1,923.71 2,212.27
35636 1,790.75 1,701.21 1,956.39
34834 302.06 286.96 330.00 # 35470 499.61 474.63 545.82 35637 1,850.74 1,758.20 2,021.93
34900 986.30 936.99 1,077.54
35001 1,231.56 1,169.98 1,345.48
35471 3,621.57 3,440.49 3,956.56
# 35471 599.11 569.15 654.52
35638 1,892.26 1,797.65 2,067.30
35642 1,129.06 1,072.61 1,233.50
35002 1,298.34 1,233.42 1,418.43
35005 1,130.64 1,074.11 1,235.23
35472 2,512.35 2,386.73 2,744.74
# 35472 399.15 379.19 436.07
35645 1,066.37 1,013.05 1,165.01
35646 1,870.27 1,776.76 2,043.27
35011 1,078.25 1,024.34 1,177.99 35473 2,402.99 2,282.84 2,625.27 35647 1,693.91 1,609.21 1,850.59
35013 1,336.71 1,269.87 1,460.35
35021 1,315.54 1,249.76 1,437.22
# 35473 353.85 336.16 386.58
35474 3,210.24 3,049.73 3,507.19
35650 1,159.73 1,101.74 1,267.00
35651 1,501.93 1,426.83 1,640.85
35022 1,482.39 1,408.27 1,619.51
35045 1,049.02 996.57 1,146.06
# 35474 427.24 405.88 466.76
35475 2,570.17 2,441.66 2,807.91
35654 1,494.93 1,420.18 1,633.21
35656 1,179.87 1,120.88 1,289.01
35081 1,871.07 1,777.52 2,044.15
35082 2,349.68 2,232.20 2,567.03
# 35475 532.96 506.31 582.26
35476 1,949.18 1,851.72 2,129.48
35661 1,182.66 1,123.53 1,292.06
35663 1,368.58 1,300.15 1,495.17
35091 1,978.62 1,879.69 2,161.64 # 35476 340.53 323.50 372.03 35665 1,282.50 1,218.38 1,401.14
35092 2,801.05 2,661.00 3,060.15
35102 2,028.70 1,927.27 2,216.36
35480 605.24 574.98 661.23
35481 438.73 416.79 479.31
35666 1,386.40 1,317.08 1,514.64
35671 1,222.26 1,161.15 1,335.32
35103 2,426.81 2,305.47 2,651.29
35111 1,499.82 1,424.83 1,638.55
35482 383.80 364.61 419.30
35483 462.56 439.43 505.34
35681 87.07 82.72 95.13
35682 388.18 368.77 424.09
35112 1,835.09 1,743.34 2,004.84 35484 573.85 545.16 626.93 35683 457.83 434.94 500.18
35121 1,778.06 1,689.16 1,942.53
35122 2,127.60 2,021.22 2,324.40
35485 535.57 508.79 585.11
35490 669.56 636.08 731.49
35685 217.99 207.09 238.15
35686 182.77 173.63 199.67
35131 1,520.08 1,444.08 1,660.69
35132 1,832.19 1,740.58 2,001.67
35491 447.74 425.35 489.15
35492 408.01 387.61 445.75
35691 1,076.18 1,022.37 1,175.73
35693 959.09 911.14 1,047.81
35141 1,205.92 1,145.62 1,317.46
35142 1,441.89 1,369.80 1,575.27
35493 497.15 472.29 543.13
35494 629.24 597.78 687.45
35694 1,110.71 1,055.17 1,213.45
35695 1,157.06 1,099.21 1,264.09
35151 1,359.03 1,291.08 1,484.74 35495 575.20 546.44 628.41 35697 162.52 154.39 177.55
35152 1,577.47 1,498.60 1,723.39
35180 909.33 863.86 993.44
35500 348.29 330.88 380.51
35501 1,695.98 1,611.18 1,852.86
35700 167.28 158.92 182.76
35701 582.17 553.06 636.02
35182 1,860.40 1,767.38 2,032.49
35184 1,095.20 1,040.44 1,196.51
35506 1,439.17 1,367.21 1,572.29
35508 1,487.63 1,413.25 1,625.24
35721 495.07 470.32 540.87
35741 540.42 513.40 590.41
35188 923.27 877.11 1,008.68 35509 1,629.35 1,547.88 1,780.06 35761 403.16 383.00 440.45
35189 1,711.08 1,625.53 1,869.36
35190 804.95 764.70 879.41
35510 1,361.81 1,293.72 1,487.78
35511 1,286.01 1,221.71 1,404.97
35800 514.86 489.12 562.49
35820 1,977.60 1,878.72 2,160.53
35201 1,008.95 958.50 1,102.28
35206 824.45 783.23 900.71
35512 1,326.69 1,260.36 1,449.41
35515 1,429.31 1,357.84 1,561.52
35840 669.65 636.17 731.60
35860 435.30 413.54 475.57
35207 757.79 719.90 827.89
35211 1,464.63 1,391.40 1,600.11
35516 1,306.64 1,241.31 1,427.51
35518 1,308.60 1,243.17 1,429.65
35870 1,388.72 1,319.28 1,517.17
35875 644.49 612.27 704.11
35216 2,021.81 1,920.72 2,208.83 35521 1,374.90 1,306.16 1,502.08 35876 1,026.80 975.46 1,121.78
35221 1,498.44 1,423.52 1,637.05
35226 910.13 864.62 994.31
35522 1,297.58 1,232.70 1,417.61
35523 1,377.12 1,308.26 1,504.50
35879 1,005.61 955.33 1,098.63
35881 1,117.94 1,062.04 1,221.35
35231 1,265.38 1,202.11 1,382.43
35236 1,052.41 999.79 1,149.76
35525 1,218.02 1,157.12 1,330.69
35526 1,800.20 1,710.19 1,966.72
35883 1,298.43 1,233.51 1,418.54
35884 1,367.75 1,299.36 1,494.26
35241 1,530.30 1,453.79 1,671.86 35531 2,190.29 2,080.78 2,392.90 35901 545.82 518.53 596.31
35246 1,660.57 1,577.54 1,814.17
35251 1,779.62 1,690.64 1,944.24
35533 1,698.88 1,613.94 1,856.03
35535 2,178.37 2,069.45 2,379.87
35903 616.57 585.74 673.60
35905 1,887.38 1,793.01 2,061.96
35256 1,105.66 1,050.38 1,207.94
35261 1,119.88 1,063.89 1,223.47
35536 1,888.56 1,794.13 2,063.25
35537 2,341.76 2,224.67 2,558.37
35907 2,076.56 1,972.73 2,268.64
36000 28.26 26.85 30.88
35266 927.49 881.12 1,013.29
35271 1,462.15 1,389.04 1,597.40
35538 2,628.86 2,497.42 2,872.03
35539 2,433.31 2,311.64 2,658.39
# 36000 10.14 9.63 11.07
36002 185.88 176.59 203.08
35276 1,534.75 1,458.01 1,676.71 35540 2,726.30 2,589.99 2,978.49 # 36002 119.61 113.63 130.67
35281 1,704.08 1,618.88 1,861.71
35286 1,017.06 966.21 1,111.14
35548 1,305.38 1,240.11 1,426.13
35549 1,419.99 1,348.99 1,551.34
36005 393.22 373.56 429.59
# 36005 53.47 50.80 58.42
CODES: 34401 - 36005
# - These amounts apply when the service is performed in a facility setting.
C - The payment for the technical component is capped at the OPPS amount.
Limiting charge applies to unassigned claims by non-participating providers. All CPT codes and modifiers are bolded.
All Current Procedural Terminology (CPT) codes and descriptors are copyrighted 2008 by the American Medical Association..

36010
36010
36011
36011
36012
36012
36013
36013
36014
36014
36015
36015
36100
36100
36120
36120
36140
36140
36145
36145
36160
36160
36200
36200
36215
36215
36216
36216
36217
36217
36218
36218
36245
36245
36246
36246
36247
36247
36248
36248
36260
36261
36262
36400
36400
36405
36405
36406
36406
36410
36410
36420
36425
36430
36440
36450
36455
36460
36470
36470
36471
36471
36475
36475
36476
36476
36478
36478
36479
36479
36481
36500
36510
36510
36511
36512
36513
36514
36514
36515
36515
36516
36516
36522
36522
36555
36555
36556
36556
36557
36557
36558
36558
36560
36560
36561
36561
36563
36563
36565
36565
36566
36566
36568
36568
36569
36569
36570
36570
36571
36571
36575
36575
36576
36576
36578
36578
36580
36580
36581
36581
36582
36582
36583
36583
36584
36584
36585
36585
36589
36589
36590
36590
36591
36592
36593
36595
36595
36596
36596
36597
36597
36598
36598
36600
36600
36620
36625
36640
36660
36680
36800
36810
36815
36818
36819
36820
36821
36822
36823
36825
36830
36831
36832
36833
36834
36835
36838
36860
36860
36861
36870
36870
37140
37145
37160
37180
37181
37182
37183
37184
37184
37185
37185
37186
37186
37187
37187
37188
37188
37195
37200
37201
37202
37203
37203
37204
37205
37205
37206
37206
37207
37208
37209
37210
37210
37215
37250
37251
37500
37565
37600
37605
37606
37607
37609
37609
37615
37616
37617
37618
37620
37650
37660
37700
37718
37722
37735
37760
37765
37766






California - MEDICARE CARRIER 01192 FSY2009 LOCALITY 18 FEE SCHEDULE PAGE: 17
PROCEDURE PAR NONPAR LIMITING
CODE/MOD FEE FEE CHARGE
PROCEDURE
CODE/MOD
PAR
FEE
NONPAR
FEE
LIMITING
CHARGE
PROCEDURE
CODE/MOD
PAR
FEE
NONPAR LIMITING
FEE CHARGE
36010 673.60 639.92 735.91
# 36010 134.15 127.44 146.56
36011 1,071.21 1,017.65 1,170.30
# 36011 173.44 164.77 189.49
36012 1,003.53 953.35 1,096.35
# 36012 195.89 186.10 214.02
36013 932.04 885.44 1,018.26
# 36013 140.74 133.70 153.76
36014 969.83 921.34 1,059.54
# 36014 170.59 162.06 186.37
36015 1,062.15 1,009.04 1,160.40
# 36015 197.08 187.23 215.31
36100 609.13 578.67 665.47
# 36100 173.06 164.41 189.07
36120 507.20 481.84 554.12
# 36120 108.24 102.83 118.25
36140 561.68 533.60 613.64
# 36140 111.92 106.32 122.27
36145 556.26 528.45 607.72
# 36145 109.14 103.68 119.23
36160 615.99 585.19 672.97
# 36160 146.34 139.02 159.87
36200 748.61 711.18 817.86
# 36200 167.18 158.82 182.64
36215 1,323.05 1,256.90 1,445.44
# 36215 266.23 252.92 290.86
36216 1,444.82 1,372.58 1,578.47
# 36216 300.08 285.08 327.84
36217 2,369.64 2,251.16 2,588.83
# 36217 359.37 341.40 392.61
36218 220.21 209.20 240.58
# 36218 57.18 54.32 62.47
36245 1,462.50 1,389.38 1,597.79
# 36245 275.34 261.57 300.81
36246 1,432.27 1,360.66 1,564.76
# 36246 299.01 284.06 326.67
36247 2,262.26 2,149.15 2,471.52
# 36247 355.82 338.03 388.73
36248 188.40 178.98 205.83
# 36248 57.18 54.32 62.47
36260 617.29 586.43 674.39
36261 379.33 360.36 414.41
36262 290.10 275.60 316.94
36400 27.51 26.13 30.05
# 36400 18.67 17.74 20.40
36405 25.32 24.05 27.66
# 36405 16.49 15.67 18.02
36406 18.54 17.61 20.25
# 36406 9.70 9.22 10.60
36410 20.74 19.70 22.66
# 36410 9.26 8.80 10.12
36420 51.00 48.45 55.72
36425 40.44 38.42 44.18
36430 43.27 41.11 47.28
36440 53.94 51.24 58.93
36450 125.16 118.90 136.74
36455 136.67 129.84 149.32
36460 354.78 337.04 387.60
36470 151.77 144.18 165.81
# 36470 74.01 70.31 80.86
36471 185.31 176.04 202.45
# 36471 103.58 98.40 113.16
36475 2,030.74 1,929.20 2,218.58
# 36475 360.23 342.22 393.55
36476 422.40 401.28 461.47
# 36476 175.42 166.65 191.65
36478 1,665.36 1,582.09 1,819.40
# 36478 364.21 346.00 397.90
36479 445.37 423.10 486.57
# 36479 176.75 167.91 193.10
36481 447.23 424.87 488.60
36500 195.90 186.11 214.03
36510 120.26 114.25 131.39
# 36510 60.61 57.58 66.22
36511 95.04 90.29 103.83
36512 96.81 91.97 105.77
36513 100.30 95.29 109.58
36514
# 36514
36515
# 36515
36516
# 36516
36522
# 36522
# 36555
36555
36556
# 36556
36557
# 36557
36558
# 36558
36560
# 36560
36561
# 36561
36563
# 36563
36565
# 36565
36566
# 36566
36568
# 36568
36569
# 36569
36570
# 36570
36571
# 36571
36575
# 36575
36576
# 36576
36578
# 36578
36580
# 36580
36581
# 36581
36582
# 36582
36583
# 36583
36584
# 36584
36585
# 36585
36589
# 36589
36590
# 36590
36591
36592
36593
36595
# 36595
36596
# 36596
36597
# 36597
36598
# 36598
36600
# 36600
36620
36625
36640
36660
36680
36800
36810
36815
593.85
94.16
2,248.01
91.95
2,550.13
66.24
1,584.11
109.33
133.41
302.19
256.22
126.77
949.31
321.49
919.49
308.02
1,308.83
378.81
1,296.35
366.77
1,309.48
380.78
1,090.02
360.58
4,178.09
385.54
350.97
103.55
304.03
104.33
1,337.97
340.35
1,389.36
329.88
183.82
42.00
397.75
200.26
563.20
230.52
262.79
75.02
863.15
217.22
1,201.39
317.76
1,201.50
317.87
259.54
78.40
1,237.62
299.21
180.11
150.07
295.58
211.63
26.80
29.45
42.10
690.94
207.59
155.53
49.93
142.45
69.11
130.41
68.11
33.80
16.13
52.72
111.50
127.35
70.32
62.38
170.06
222.26
158.44
564.16
89.45
2,135.61
87.35
2,422.62
62.93
1,504.90
103.86
126.74
287.08
243.41
120.43
901.84
305.42
873.52
292.62
1,243.39
359.87
1,231.53
348.43
1,244.01
361.74
1,035.52
342.55
3,969.19
366.26
333.42
98.37
288.83
99.11
1,271.07
323.33
1,319.89
313.39
174.63
39.90
377.86
190.25
535.04
218.99
249.65
71.27
819.99
206.36
1,141.32
301.87
1,141.43
301.98
246.56
74.48
1,175.74
284.25
171.10
142.57
280.80
201.05
25.46
27.98
40.00
656.39
197.21
147.75
47.43
135.33
65.65
123.89
64.70
32.11
15.32
50.08
105.93
120.98
66.80
59.26
161.56
211.15
150.52
648.78
102.87
2,455.95
100.45
2,786.01
72.37
1,730.64
119.44
145.75
330.14
279.92
138.49
1,037.12
351.23
1,004.55
336.51
1,429.90
413.85
1,416.26
400.69
1,430.61
416.00
1,190.85
393.93
4,564.57
421.20
383.43
113.13
332.15
113.98
1,461.73
371.83
1,517.87
360.40
200.82
45.89
434.54
218.79
615.30
251.84
287.10
81.96
942.99
237.31
1,312.52
347.15
1,312.64
347.28
283.54
85.65
1,352.10
326.89
196.77
163.96
322.92
231.21
29.28
32.18
46.00
754.85
226.79
169.91
54.54
155.63
75.50
142.47
74.41
36.93
17.62
57.59
121.82
139.13
76.82
68.15
185.79
242.82
173.10
36818
36819
36820
36821
36822
36823
36825
36830
36831
36832
36833
36834
36835
36838
36860
# 36860
36861
36870
# 36870
37140
37145
37160
37180
37181
37182
37183
37184
# 37184
37185
# 37185
37186
# 37186
37187
# 37187
37188
# 37188
37195
37200
37201
37202
37203
# 37203
37204
37205
# 37205
37206
# 37206
37207
37208
37209
37210
# 37210
37215
37250
37251
37500
37565
37600
37605
37606
37607
37609
# 37609
37615
37616
37617
37618
37620
37650
37660
37700
37718
37722
37735
37760
37765
37766
721.18
845.85
849.10
705.35
406.07
1,351.92
616.07
700.15
485.66
618.01
697.54
655.67
490.73
1,244.56
209.88
108.70
161.21
2,129.72
332.41
1,420.56
1,539.94
1,335.90
1,494.83
1,615.87
967.02
460.30
2,788.31
494.84
918.76
181.37
1,886.16
279.71
2,673.81
459.87
2,280.44
333.80
371.29
256.42
306.49
371.15
1,544.43
292.76
1,018.00
3,860.66
480.77
2,312.67
233.48
463.72
223.49
125.36
4,083.78
608.45
1,202.82
119.40
88.56
736.83
728.33
744.10
850.64
558.79
399.32
312.48
207.33
494.69
1,143.06
1,351.27
397.02
713.15
539.88
1,265.35
267.88
434.88
503.26
668.81
658.28
474.02
574.19
685.12 787.89
803.56 924.09
806.65 927.65
670.08 770.59
385.77 443.64
1,284.32 1,476.97
585.27 673.06
665.14 764.91
461.38 530.59
587.11 675.18
662.66 762.06
622.89 716.32
466.19 536.12
1,182.33 1,359.68
199.39 229.30
103.27 118.76
153.15 176.12
2,023.23 2,326.71
315.79 363.16
1,349.53 1,551.96
1,462.94 1,682.38
1,269.11 1,459.48
1,420.09 1,633.10
1,535.08 1,765.34
918.67 1,056.47
437.29 502.88
2,648.89 3,046.22
470.10 540.62
872.82 1,003.74
172.30 198.15
1,791.85 2,060.63
265.72 305.58
2,540.12 2,921.14
436.88 502.41
2,166.42 2,491.38
317.11 364.68
352.73 405.64
243.60 280.14
291.17 334.85
352.59 405.48
1,467.21 1,687.29
278.12 319.84
967.10 1,112.17
3,667.63 4,217.77
456.73 525.24
2,197.04 2,526.60
221.81 255.08
440.53 506.61
212.32 244.17
119.09 136.95
3,879.59 4,461.53
578.03 664.73
1,142.68 1,314.08
113.43 130.44
84.13 96.75
699.99 804.99
691.91 795.70
706.90 812.94
808.11 929.33
530.85 610.48
379.35 436.25
296.86 341.39
196.96 226.50
469.96 540.45
1,085.91 1,248.80
1,283.71 1,476.27
377.17 433.75
677.49 779.11
512.89 589.82
1,202.08 1,382.39
254.49 292.66
413.14 475.11
478.10 549.82
635.37 730.68
625.37 719.18
450.32 517.87
545.48 627.30
CODES: 36010 - 37766
# - These amounts apply when the service is performed in a facility setting.
C - The payment for the technical component is capped at the OPPS amount.
Limiting charge applies to unassigned claims by non-participating providers. All CPT codes and modifiers are bolded.
All Current Procedural Terminology (CPT) codes and descriptors are copyrighted 2008 by the American Medical Association.

37780
37785
37785
37788
37790
38100
38101
38102
38115
38120
38200
38205
38206
38220
38220
38221
38221
38230
38240
38241
38242
38300
38300
38305
38308
38380
38381
38382
38500
38500
38505
38505
38510
38510
38520
38525
38530
38542
38550
38555
38562
38564
38570
38571
38572
38700
38720
38724
38740
38745
38746
38747
38760
38765
38770
38780
38790
38792
38794
39000
39010
39200
39220
39400
39501
39502
39503
39520
39530
39531
39540
39541
39545
39560
39561
40490
40490
40500
40500
40510
40510
40520
40520
40525
40527
40530
40530
40650
40650
40652
40652
40654
40654
40700
40701
40702
40720
40761
40800
40800
40801
40801
40804
40804
40805
40805
40806
40806
40808
40808
40810
40810
40812
40812
40814
40814
40816
40816
40818
40818
40819
40819
40820
40820
40830
40830
40831
40831
40840
40840
40842
40842
40843
40843
40844
40844
40845
40845
41000
41000
41005
41005
41006
41006
41007
41007
41008
41008
41009
41009
41010
41010
41015
41015
41016
41016
41017
41017
41018
41018
41019
41100
41100
41105
41105
41108
41108
41110
41110
41112
41112
41113
41113
41114
41115
41115
41116
41116
41120
41130
41135
41140
41145
41150
41153
41155
41250
41250
41251
41251
41252
41252
41500
41510
41512
41520
41520
41530
41530
41800
41800
41805
41805
41806
41806
41822
41822
41823
41823
41825
41825
41826
41826
41827
41827
41828
41828
41830
41830
41872
41872
41874
41874
42000
42000
42100
42100
42104
42104
42106
42106






California - MEDICARE CARRIER 01192 FSY2009 LOCALITY 18 FEE SCHEDULE PAGE: 18
PROCEDURE PAR NONPAR CHARGE
CODE/MOD FEE FEE LIMIT
PROCEDURE PAR NONPAR CHARGE
CODE/MOD FEE FEE LIMIT
PROCEDURE PAR NONPAR CHARGE
CODE/MOD FEE FEE LIMIT
37780 276.42 262.60 301.99
37785 380.10 361.10 415.27
40500 509.24 483.78 556.35
# 40500 366.97 348.62 400.91
41016 440.07 418.07 480.78
# 41016 354.36 336.64 387.14
# 37785 277.16 263.30 302.80 40510 489.52 465.04 534.80 41017 443.61 421.43 484.64
37788 1,463.16 1,390.00 1,598.50
37790 531.06 504.51 580.19
# 40510 360.06 342.06 393.37
40520 504.28 479.07 550.93
# 41017 356.13 338.32 389.07
41018 505.18 479.92 551.91
38100 1,092.86 1,038.22 1,193.95
38101 1,099.28 1,044.32 1,200.97
# 40520 364.67 346.44 398.41
40525 564.41 536.19 616.62
# 41018 414.17 393.46 452.48
41019 504.97 479.72 551.68
38102 260.41 247.39 284.50 40527 665.14 631.88 726.66 41100 171.85 163.26 187.75
38115 1,214.43 1,153.71 1,326.77
38120 1,020.94 969.89 1,115.37
40530 554.58 526.85 605.88
# 40530 412.76 392.12 450.94
# 41100 111.76 106.17 122.10
41105 171.82 163.23 187.71
38200 146.48 139.16 160.03
38205 84.86 80.62 92.71
40650 420.39 399.37 459.28
# 40650 290.94 276.39 317.85
# 41105 113.06 107.41 123.52
41108 148.67 141.24 162.43
38206 84.86 80.62 92.71
38220 172.33 163.71 188.27
40652 494.94 470.19 540.72
# 40652 356.21 338.40 389.16
# 41108 91.67 87.09 100.15
41110 214.08 203.38 233.89
# 38220 64.09 60.89 70.02 40654 581.75 552.66 635.56 # 41110 134.11 127.40 146.51
38221 189.99 180.49 207.56
# 38221 81.30 77.24 88.83
# 40654 431.53 409.95 471.44
40700 935.99 889.19 1,022.57
41112 335.24 318.48 366.25
# 41112 255.71 242.92 279.36
38230 333.31 316.64 364.14
38240 131.91 125.31 144.11
40701 1,163.96 1,105.76 1,271.62
40702 896.48 851.66 979.41
41113 366.18 347.87 400.05
# 41113 283.12 268.96 309.30
38241 132.80 126.16 145.08 40720 996.18 946.37 1,088.33 41114 646.22 613.91 706.00
38242 100.54 95.51 109.84
38300 280.62 266.59 306.58
40761 1,079.20 1,025.24 1,179.03
# 40800 130.63 124.10 142.72
41115 249.35 236.88 272.41
# 41115 151.27 143.71 165.27
# 38300 183.87 174.68 200.88
38305 460.54 437.51 503.14
40800 207.50 197.13 226.70
40801 313.13 297.47 342.09
41116 330.03 313.53 360.56
# 41116 223.56 212.38 244.24
38308 438.59 416.66 479.16
38380 567.87 539.48 620.40
# 40801 223.45 212.28 244.12
40804 211.32 200.75 230.86
41120 1,080.23 1,026.22 1,180.15
41130 1,318.85 1,252.91 1,440.85
38381 839.16 797.20 916.78 # 40804 131.79 125.20 143.98 41135 2,171.08 2,062.53 2,371.91
38382 679.98 645.98 742.88
38500 320.62 304.59 350.28
40805 327.83 311.44 358.16
# 40805 231.07 219.52 252.45
41140 2,245.86 2,133.57 2,453.61
41145 2,801.88 2,661.79 3,061.06
# 38500 247.28 234.92 270.16
38505 138.19 131.28 150.97
40806 112.21 106.60 122.59
# 40806 35.33 33.56 38.59
41150 2,217.29 2,106.43 2,422.39
41153 2,395.54 2,275.76 2,617.12
# 38505 79.43 75.46 86.78 40808 187.26 177.90 204.59 41155 2,960.29 2,812.28 3,234.12
38510 514.17 488.46 561.73
# 38510 416.97 396.12 455.54
# 40808 109.94 104.44 120.11
40810 206.57 196.24 225.68
41250 230.99 219.44 252.36
# 41250 142.63 135.50 155.83
38520 458.93 435.98 501.38
38525 415.36 394.59 453.78
# 40810 129.26 122.80 141.22
40812 287.35 272.98 313.93
41251 236.83 224.99 258.74
# 41251 165.70 157.42 181.03
38530 533.47 506.80 582.82
38542 510.50 484.98 557.73
# 40812 198.98 189.03 217.38
40814 384.42 365.20 419.98
41252 310.65 295.12 339.39
# 41252 214.33 203.61 234.15
38550 474.85 451.11 518.78 # 40814 308.43 293.01 336.96 41500 463.69 440.51 506.59
38555 981.23 932.17 1,072.00
38562 706.35 671.03 771.68
40816 404.56 384.33 441.98
# 40816 321.94 305.84 351.72
41510 425.60 404.32 464.97
41512 640.26 608.25 699.49
38564 697.21 662.35 761.70
38570 568.08 539.68 620.63
40818 359.61 341.63 392.87
# 40818 278.75 264.81 304.53
41520 351.74 334.15 384.27
# 41520 259.40 246.43 283.39
38571 893.21 848.55 975.83 40819 308.05 292.65 336.55 41530 3,404.00 3,233.80 3,718.87
38572 975.14 926.38 1,065.34
38700 789.88 750.39 862.95
# 40819 238.24 226.33 260.28
40820 272.46 258.84 297.67
# 41530 419.53 398.55 458.33
41800 234.47 222.75 256.16
38720 1,306.68 1,241.35 1,427.55
38724 1,415.90 1,345.11 1,546.88
# 40820 177.92 169.02 194.37
40830 246.86 234.52 269.70
# 41800 132.41 125.79 144.66
41805 241.81 229.72 264.18
38740 661.34 628.27 722.51
38745 839.57 797.59 917.23
# 40830 161.59 153.51 176.54
40831 326.56 310.23 356.76
# 41805 170.23 161.72 185.98
41806 347.39 330.02 379.52
38746 273.46 259.79 298.76 # 40831 227.15 215.79 248.16 # 41806 259.91 246.91 283.95
38747 265.40 252.13 289.95
38760 828.52 787.09 905.15
40840 817.91 777.01 893.56
# 40840 641.18 609.12 700.49
41822 291.18 276.62 318.11
# 41822 177.19 168.33 193.58
38765 1,281.98 1,217.88 1,400.56
38770 865.03 821.78 945.05
40842 804.21 764.00 878.60
# 40842 626.16 594.85 684.08
41823 432.68 411.05 472.71
# 41823 324.44 308.22 354.45
38780 1,089.64 1,035.16 1,190.43 40843 1,043.42 991.25 1,139.94 41825 210.56 200.03 230.03
38790 85.78 81.49 93.71
38792 42.47 40.35 46.40
# 40843 807.05 766.70 881.71
40844 1,385.26 1,316.00 1,513.40
# 41825 129.26 122.80 141.22
41826 292.66 278.03 319.73
38794 328.83 312.39 359.25
39000 508.05 482.65 555.05
# 40844 1,136.52 1,079.69 1,241.64
40845 1,499.34 1,424.37 1,638.03
# 41826 206.94 196.59 226.08
41827 432.58 410.95 472.59
39010 836.62 794.79 914.01
39200 923.10 876.95 1,008.49
# 40845 1,269.15 1,205.69 1,386.54
41000 162.61 154.48 177.65
# 41827 305.34 290.07 333.58
41828 306.25 290.94 334.58
39220 1,188.05 1,128.65 1,297.95 # 41000 113.13 107.47 123.59 # 41828 218.33 207.41 238.52
39400 521.19 495.13 569.40
39501 845.28 803.02 923.47
41005 232.24 220.63 253.72
# 41005 130.62 124.09 142.70
41830 390.61 371.08 426.74
# 41830 283.25 269.09 309.45
39502 1,010.75 960.21 1,104.24
39503 5,821.97 5,530.87 6,360.50
41006 364.37 346.15 398.07
# 41006 262.75 249.61 287.05
41872 368.53 350.10 402.62
# 41872 265.15 251.89 289.67
39520 1,013.18 962.52 1,106.90 41007 366.35 348.03 400.23 41874 372.68 354.05 407.16
39530 967.51 919.13 1,057.00
39531 1,008.62 958.19 1,101.92
# 41007 255.45 242.68 279.08
41008 375.76 356.97 410.52
# 41874 258.25 245.34 282.14
42000 160.87 152.83 175.75
39540 861.18 818.12 940.84
39541 928.83 882.39 1,014.75
# 41008 272.38 258.76 297.57
41009 399.10 379.15 436.02
# 42000 104.75 99.51 114.44
42100 151.79 144.20 165.83
39545 921.97 875.87 1,007.25
39560 793.30 753.64 866.69
# 41009 296.16 281.35 323.55
41010 209.14 198.68 228.48
# 42100 111.14 105.58 121.42
42104 212.76 202.12 232.44
39561 1,237.15 1,175.29 1,351.58 # 41010 112.39 106.77 122.79 # 42104 139.86 132.87 152.80
40490 134.29 127.58 146.72
# 40490 74.65 70.92 81.56
41015 428.61 407.18 468.26
# 41015 341.13 324.07 372.68
42106 269.76 256.27 294.71
# 42106 183.60 174.42 200.58
CODES: 37780 - 42106
# - These amounts apply when the service is performed in a facility setting.
C - The payment for the technical component is capped at the OPPS amount.
Limiting charge applies to unassigned claims by non-participating providers. All CPT codes and modifiers are bolded.
All Current Procedural Terminology (CPT) codes and descriptors are copyrighted 2008 by the American Medical Association..

42107
42107
42120
42140
42140
42145
42160
42160
42180
42180
42182
42182
42200
42205
42210
42215
42220
42225
42226
42227
42235
42260
42260
42280
42280
42281
42281
42300
42300
42305
42310
42310
42320
42320
42330
42330
42335
42335
42340
42340
42400
42400
42405
42405
42408
42408
42409
42409
42410
42415
42420
42425
42426
42440
42450
42450
42500
42500
42505
42505
42507
42508
42509
42510
42550
42550
42600
42600
42650
42650
42660
42660
42665
42665
42700
42700
42720
42720
42725
42800
42800
42802
42802
42804
42804
42806
42806
42808
42808
42809
42809
42810
42810
42815
42820
42821
42825
42826
42830
42831
42835
42836
42842
42844
42845
42860
42870
42890
42892
42894
42900
42950
42953
42955
42960
42961
42962
42970
42971
42972
43020
43030
43045
43100
43101
43107
43108
43112
43113
43116
43117
43118
43121
43122
43123
43124
43130
43135
43200
43200
43201
43201
43202
43202
43204
43205
43215
43216
43216
43217
43217
43219
43220
43226
43227
43228
43231
43232
43234
43234
43235
43235
43236
43236
43237
43238
43239
43239
43240
43241
43242
43243
43244
43245
43246
43247
43248
43249
43250
43251
43255
43256
43257
43258
43259
43260
43261
43262
43263
43264
43265
43267
43268
43269
43271
43272
43273
43279
43280
43300
43305
43310
43312
43313
43314
43320
43324
43325
43326
43330
43331
43340
43341
43350
43351
43352
43360
43361
43400
43401
43405
43410
43415
43420
43425
43450
43450
43453
43453
43456
43456






California - MEDICARE CARRIER 01192 FSY2009 LOCALITY 18 FEE SCHEDULE PAGE: 19
PROCEDURE PAR NONPAR LIMITING
CODE/MOD FEE FEE CHARGE
PROCEDURE
CODE/MOD
PAR
FEE
NONPAR
FEE
LIMITING
CHARGE
PROCEDURE
CODE/MOD
PAR
FEE
NONPAR LIMITING
FEE CHARGE
42107 462.84 439.70 505.66
# 42107 350.62 333.09 383.05
42120 993.37 943.70 1,085.26
42140 256.58 243.75 280.31
# 42140 158.94 150.99 173.64
42145 713.98 678.28 780.02
42160 246.45 234.13 269.25
# 42160 156.32 148.50 170.78
42180 245.62 233.34 268.34
# 42180 187.30 177.94 204.63
42182 333.38 316.71 364.22
# 42182 271.97 258.37 297.13
42200 903.49 858.32 987.07
42205 960.45 912.43 1,049.29
42210 1,086.63 1,032.30 1,187.15
42215 719.54 683.56 786.09
42220 557.89 530.00 609.50
42225 977.45 928.58 1,067.87
42226 966.02 917.72 1,055.38
42227 940.17 893.16 1,027.13
42235 768.45 730.03 839.53
42260 847.40 805.03 925.78
# 42260 693.65 658.97 757.82
42280 159.51 151.53 174.26
# 42280 105.17 99.91 114.90
42281 206.71 196.37 225.83
# 42281 155.46 147.69 169.84
42300 211.72 201.13 231.30
# 42300 155.61 147.83 170.00
42305 439.12 417.16 479.73
42310 164.27 156.06 179.47
# 42310 127.15 120.79 138.91
42320 254.57 241.84 278.12
# 42320 181.67 172.59 198.48
42330 236.80 224.96 258.70
# 42330 168.32 159.90 183.89
42335 378.95 360.00 414.00
# 42335 264.96 251.71 289.47
42340 473.13 449.47 516.89
# 42340 346.77 329.43 378.84
42400 114.09 108.39 124.65
# 42400 60.63 57.60 66.24
42405 309.12 293.66 337.71
# 42405 233.13 221.47 254.69
42408 462.91 439.76 505.72
# 42408 335.67 318.89 366.72
42409 338.39 321.47 369.69
# 42409 229.71 218.22 250.95
42410 633.40 601.73 691.99
42415 1,136.63 1,079.80 1,241.77
42420 1,301.07 1,236.02 1,421.42
42425 859.77 816.78 939.30
42426 1,390.50 1,320.98 1,519.13
42440 477.09 453.24 521.23
42450 461.95 438.85 504.68
# 42450 368.28 349.87 402.35
42500 441.25 419.19 482.07
# 42500 351.12 333.56 383.59
42505 568.41 539.99 620.99
# 42505 466.79 443.45 509.97
42507 530.90 504.36 580.01
42508 751.87 714.28 821.42
42509 853.17 810.51 932.09
42510 649.14 616.68 709.18
42550 160.30 152.29 175.13
# 42550 69.73 66.24 76.18
42600 496.26 471.45 542.17
# 42600 363.27 345.11 396.88
42650 85.28 81.02 93.17
# 42650 60.98 57.93 66.62
42660 108.66 103.23 118.71
# 42660 80.38 76.36 87.81
42665 317.44 301.57 346.81
# 42665 213.17 202.51 232.89
42700 192.59 182.96 210.40
# 42700 139.57 132.59 152.48
42720 463.95 440.75 506.86
# 42720
42725
42800
# 42800
42802
# 42802
42804
# 42804
42806
# 42806
42808
# 42808
42809
# 42809
42810
# 42810
42815
42820
42821
42825
42826
42830
42831
42835
42836
42842
42844
42845
42860
42870
42890
42892
42894
42900
42950
42953
42955
42960
42961
42962
42970
42971
42972
43020
43030
43045
43100
43101
43107
43108
43112
43113
43116
43117
43118
43121
43122
43123
43124
43130
43135
43200
# 43200
43201
# 43201
43202
# 43202
43204
43205
43215
43216
# 43216
43217
# 43217
43219
43220
43226
402.98
826.32
161.28
114.89
250.26
140.69
209.26
119.57
234.82
139.39
233.55
168.61
173.20
132.11
397.40
294.01
570.14
298.54
312.03
269.33
259.63
212.99
230.24
192.10
249.56
995.88
1,394.91
2,255.34
193.52
600.06
1,411.48
1,844.55
2,358.81
353.37
825.62
1,020.87
775.63
173.71
432.13
533.39
396.79
469.31
526.02
537.62
533.77
1,342.26
637.36
1,048.02
2,577.76
4,279.96
2,753.09
4,296.82
4,874.22
2,516.12
3,531.65
2,819.35
2,544.54
4,304.03
3,693.85
804.87
1,483.48
230.03
108.53
316.98
135.84
303.73
119.49
235.14
235.75
160.99
207.69
150.25
404.04
176.51
179.68
132.82
148.15
382.83
785.00
153.22
109.15
237.75
133.66
198.80
113.59
223.08
132.42
221.87
160.18
164.54
125.50
377.53
279.31
541.63
283.61
296.43
255.86
246.65
202.34
218.73
182.50
237.08
946.09
1,325.16
2,142.57
183.84
570.06
1,340.91
1,752.32
2,240.87
335.70
784.34
969.83
736.85
165.02
410.52
506.72
376.95
445.84
499.72
510.74
507.08
1,275.15
605.49
995.62
2,448.87
4,065.96
2,615.44
4,081.98
4,630.51
2,390.31
3,355.07
2,678.38
2,417.31
4,088.83
3,509.16
764.63
1,409.31
218.53
103.10
301.13
129.05
288.54
113.52
223.38
223.96
152.94
197.31
142.74
383.84
167.68
170.70
126.18
140.74
440.25
902.75
176.20
125.52
273.41
153.71
228.62
130.63
256.54
152.28
255.15
184.21
189.22
144.33
434.16
321.21
622.87
326.15
340.89
294.24
283.65
232.69
251.54
209.88
272.64
1,088.00
1,523.93
2,463.96
211.42
655.57
1,542.05
2,015.17
2,577.00
386.06
901.99
1,115.30
847.38
189.77
472.10
582.73
433.49
512.72
574.68
587.35
583.14
1,466.42
696.31
1,144.96
2,816.20
4,675.85
3,007.76
4,694.28
5,325.09
2,748.86
3,858.33
3,080.14
2,779.91
4,702.15
4,035.53
879.32
1,620.71
251.31
118.57
346.30
148.41
331.82
130.55
256.89
257.55
175.88
226.91
164.15
441.42
192.83
196.31
145.11
161.85
43227
43228
43231
43232
43234
# 43234
43235
# 43235
43236
# 43236
43237
43238
43239
# 43239
43240
43241
43242
43243
43244
43245
43246
43247
43248
43249
43250
43251
43255
43256
43257
43258
43259
43260
43261
43262
43263
43264
43265
43267
43268
43269
43271
43272
43273
43279
43280
43300
43305
43310
43312
43313
43314
43320
43324
43325
43326
43330
43331
43340
43341
43350
43351
43352
43360
43361
43400
43401
43405
43410
43415
43420
43425
43450
# 43450
43453
# 43453
43456
# 43456
219.78
234.97
200.22
275.33
300.42
124.58
323.22
152.68
402.90
185.53
252.47
312.28
373.48
180.41
418.34
163.86
446.29
281.51
312.18
196.74
263.07
210.72
199.60
183.74
196.61
229.13
298.10
267.66
327.39
280.76
319.88
366.20
384.89
451.80
447.16
542.17
608.25
449.59
457.98
500.67
451.36
450.47
136.46
1,258.52
1,052.97
634.96
1,126.19
1,561.69
1,721.82
2,727.98
3,143.57
1,370.80
1,326.23
1,305.63
1,336.65
1,280.50
1,395.94
1,329.91
1,472.86
1,136.86
1,340.74
1,098.20
2,334.94
2,601.38
1,623.26
1,516.42
1,477.28
1,015.45
1,721.14
1,013.42
1,514.86
170.76
93.88
328.51
101.86
668.26
163.26
208.79 240.11
223.22 256.70
190.21 218.74
261.56 300.79
285.40 328.21
118.35 136.10
307.06 353.12
145.05 166.81
382.76 440.17
176.25 202.69
239.85 275.83
296.67 341.17
354.81 408.03
171.39 197.10
397.42 457.03
155.67 179.02
423.98 487.58
267.43 307.54
296.57 341.06
186.90 214.94
249.92 287.41
200.18 230.21
189.62 218.06
174.55 200.73
186.78 214.80
217.67 250.32
283.20 325.68
254.28 292.42
311.02 357.67
266.72 306.73
303.89 349.47
347.89 400.07
365.65 420.50
429.21 493.59
424.80 488.52
515.06 592.32
577.84 664.52
427.11 491.18
435.08 500.34
475.64 546.99
428.79 493.11
427.95 492.14
129.64 149.09
1,195.59 1,374.93
1,000.32 1,150.37
603.21 693.69
1,069.88 1,230.36
1,483.61 1,706.15
1,635.73 1,881.09
2,591.58 2,980.32
2,986.39 3,434.35
1,302.26 1,497.60
1,259.92 1,448.91
1,240.35 1,426.40
1,269.82 1,460.29
1,216.48 1,398.95
1,326.14 1,525.06
1,263.41 1,452.92
1,399.22 1,609.10
1,080.02 1,242.02
1,273.70 1,464.76
1,043.29 1,199.78
2,218.19 2,550.92
2,471.31 2,842.01
1,542.10 1,773.42
1,440.60 1,656.69
1,403.42 1,613.93
964.68 1,109.38
1,635.08 1,880.34
962.75 1,107.16
1,439.12 1,654.99
162.22 186.55
89.19 102.57
312.08 358.89
96.77 111.29
634.85 730.08
155.10 178.37
CODES: 42107 - 43456
# - These amounts apply when the service is performed in a facility setting.
C - The payment for the technical component is capped at the OPPS amount.
Limiting charge applies to unassigned claims by non-participating providers. All CPT codes and modifiers are bolded.
All Current Procedural Terminology (CPT) codes and descriptors are copyrighted 2008 by the American Medical Association.

43458
43458
43460
43496
43500
43501
43502
43510
43520
43600
43605
43610
43611
43620
43621
43622
43631
43632
43633
43634
43635
43640
43641
43644
43645
43651
43652
43653
43752
43760
43760
43761
43761
43770
43771
43772
43773
43774
43800
43810
43820
43825
43830
43831
43832
43840
43843
43845
43846
43847
43848
43850
43855
43860
43865
43870
43880
43886
43887
43888
44005
44010
44015
44020
44021
44025
44050
44055
44100
44110
44111
44120
44121
44125
44126
44127
44128
44130
44137
44139
44140
44141
44143
44144
44145
44146
44147
44150
44151
44155
44156
44157
44158
44160
44180
44186
44187
44188
44202
44203
44204
44205
44206
44207
44208
44210
44211
44212
44213
44227
44300
44310
44312
44314
44316
44320
44322
44340
44345
44346
44360
44361
44363
44364
44365
44366
44369
44370
44372
44373
44376
44377
44378
44379
44380
44382
44383
44385
44385
44386
44386
44388
44388
44389
44389
44390
44390
44391
44391
44392
44392
44393
44393
44394
44394
44397
44500
44602
44603
44604
44605
44615
44620
44625
44626
44640
44650
44660
44661
44680
44700
44701
44715
44720
44721
44800
44820
44850
44900
44901
44901
44950
44955
44960
44970
45000
45005
45005
45020
45100
45108
45110
45111
45112
45113
45114
45116
45119
45120
45121
45123
45126
45130
45135
45136
45150
45160
45170
45190
45300
45300
45303
45303
45305
45305
45307
45307
45308
45308
45309
45309
45315
45315
45317
45317
45320
45320
45321
45327
45330
45330






California - MEDICARE CARRIER 01192 FSY2009 LOCALITY 18 FEE SCHEDULE PAGE: 20
PROCEDURE PAR NONPAR CHARGE
CODE/MOD FEE FEE LIMIT
PROCEDURE PAR NONPAR CHARGE
CODE/MOD FEE FEE LIMIT
PROCEDURE PAR NONPAR CHARGE
CODE/MOD FEE FEE LIMIT
43458 419.19 398.23 457.96
# 43458 190.33 180.81 207.93
44130 1,224.38 1,163.16 1,337.63
44137 1,078.17 1,024.26 1,177.90
# 44394 267.98 254.58 292.77
44397 289.83 275.34 316.64
43460 230.37 218.85 251.68 44139 120.12 114.11 131.23 44500 27.22 25.86 29.74
43496 982.02 932.92 1,072.86
43500 754.29 716.58 824.07
44140 1,297.39 1,232.52 1,417.40
44141 1,708.15 1,622.74 1,866.15
44602 1,320.60 1,254.57 1,442.76
44603 1,515.34 1,439.57 1,655.51
43501 1,292.50 1,227.88 1,412.06
43502 1,462.65 1,389.52 1,597.95
44143 1,599.45 1,519.48 1,747.40
44144 1,674.42 1,590.70 1,829.31
44604 1,021.86 970.77 1,116.39
44605 1,262.24 1,199.13 1,379.00
43510 938.28 891.37 1,025.08 44145 1,613.34 1,532.67 1,762.57 44615 1,040.16 988.15 1,136.37
43520 684.76 650.52 748.10
43600 111.12 105.56 121.39
44146 2,021.30 1,920.24 2,208.28
44147 1,807.44 1,717.07 1,974.63
44620 831.30 789.74 908.20
44625 982.92 933.77 1,073.84
43605 799.61 759.63 873.57
43610 943.32 896.15 1,030.57
44150 1,778.78 1,689.84 1,943.32
44151 2,030.32 1,928.80 2,218.12
44626 1,559.06 1,481.11 1,703.28
44640 1,361.31 1,293.24 1,487.23
43611 1,173.79 1,115.10 1,282.37
43620 1,905.80 1,810.51 2,082.09
44155 1,987.79 1,888.40 2,171.66
44156 2,187.45 2,078.08 2,389.79
44650 1,416.10 1,345.30 1,547.10
44660 1,377.37 1,308.50 1,504.78
43621 2,163.73 2,055.54 2,363.87 44157 2,076.47 1,972.65 2,268.55 44661 1,539.21 1,462.25 1,681.59
43622 2,196.23 2,086.42 2,399.38
43631 1,401.46 1,331.39 1,531.10
44158 2,127.51 2,021.13 2,324.30
44160 1,194.86 1,135.12 1,305.39
44680 1,027.09 975.74 1,122.10
44700 993.82 944.13 1,085.75
43632 1,895.56 1,800.78 2,070.90
43633 1,806.15 1,715.84 1,973.22
44180 893.31 848.64 975.94
44186 633.41 601.74 692.00
44701 166.00 157.70 181.36
44715 355.62 337.84 388.52
43634 1,994.43 1,894.71 2,178.92 44187 1,068.42 1,015.00 1,167.25 44720 273.12 259.46 298.38
43635 111.24 105.68 121.53
43640 1,128.17 1,071.76 1,232.52
44188 1,181.25 1,122.19 1,290.52
44202 1,342.54 1,275.41 1,466.72
44721 382.84 363.70 418.26
44800 737.45 700.58 805.67
43641 1,137.27 1,080.41 1,242.47
43644 1,666.18 1,582.87 1,820.30
44203 238.90 226.96 261.00
44204 1,496.53 1,421.70 1,634.96
44820 811.01 770.46 886.03
44850 715.54 679.76 781.72
43645 1,781.91 1,692.81 1,946.73
43651 631.86 600.27 690.31
44205 1,307.39 1,242.02 1,428.32
44206 1,699.68 1,614.70 1,856.91
44900 732.28 695.67 800.02
44901 1,098.27 1,043.36 1,199.86
43652 737.63 700.75 805.86 44207 1,780.24 1,691.23 1,944.91 # 44901 187.69 178.31 205.06
43653 541.41 514.34 591.49
43752 43.36 41.19 47.37
44208 1,941.37 1,844.30 2,120.95
44210 1,738.39 1,651.47 1,899.19
44950 620.29 589.28 677.67
44955 83.57 79.39 91.30
43760 375.27 356.51 409.99
# 43760 52.75 50.11 57.63
44211 2,132.59 2,025.96 2,329.85
44212 2,002.24 1,902.13 2,187.45
44960 833.63 791.95 910.74
44970 572.76 544.12 625.74
43761 129.16 122.70 141.11 44213 188.35 178.93 205.77 45000 402.94 382.79 440.21
# 43761 112.37 106.75 122.76
43770 1,074.77 1,021.03 1,174.18
44227 1,620.10 1,539.10 1,769.97
44300 810.72 770.18 885.71
45005 256.42 243.60 280.14
# 45005 152.15 144.54 166.22
43771 1,223.54 1,162.36 1,336.71
43772 925.19 878.93 1,010.77
44310 1,010.39 959.87 1,103.85
44312 579.77 550.78 633.40
45020 523.32 497.15 571.72
45100 282.50 268.38 308.64
43773 1,224.71 1,163.47 1,337.99
43774 926.13 879.82 1,011.79
44314 980.99 931.94 1,071.73
44316 1,337.30 1,270.44 1,461.01
45108 341.97 324.87 373.60
45110 1,790.39 1,700.87 1,956.00
43800 895.95 851.15 978.82 44320 1,153.88 1,096.19 1,260.62 45111 1,052.03 999.43 1,149.34
43810 969.78 921.29 1,059.48
43820 1,251.41 1,188.84 1,367.17
44322 937.34 890.47 1,024.04
44340 585.40 556.13 639.55
45112 1,833.84 1,742.15 2,003.47
45113 1,886.57 1,792.24 2,061.08
43825 1,247.61 1,185.23 1,363.01
43830 670.05 636.55 732.03
44345 1,011.78 961.19 1,105.37
44346 1,133.41 1,076.74 1,238.25
45114 1,719.75 1,633.76 1,878.82
45116 1,545.06 1,467.81 1,687.98
43831 564.96 536.71 617.22 44360 166.37 158.05 181.76 45119 1,887.70 1,793.32 2,062.32
43832 1,025.76 974.47 1,120.64
43840 1,269.44 1,205.97 1,386.87
44361 183.21 174.05 200.16
44363 216.18 205.37 236.18
45120 1,511.47 1,435.90 1,651.29
45121 1,652.29 1,569.68 1,805.13
43843 1,216.24 1,155.43 1,328.74
43845 1,879.04 1,785.09 2,052.85
44364 233.14 221.48 254.70
44365 207.67 197.29 226.88
45123 1,071.49 1,017.92 1,170.61
45126 2,793.09 2,653.44 3,051.46
43846 1,568.16 1,489.75 1,713.21
43847 1,710.51 1,624.98 1,868.73
44366 274.77 261.03 300.18
44369 280.52 266.49 306.46
45130 1,047.20 994.84 1,144.07
45135 1,284.88 1,220.64 1,403.74
43848 1,857.15 1,764.29 2,028.93 44370 302.79 287.65 330.80 45136 1,779.64 1,690.66 1,944.26
43850 1,553.85 1,476.16 1,697.58
43855 1,624.89 1,543.65 1,775.20
44372 266.36 253.04 291.00
44373 216.18 205.37 236.18
45150 388.96 369.51 424.94
45160 957.14 909.28 1,045.67
43860 1,578.73 1,499.79 1,724.76
43865 1,641.78 1,559.69 1,793.64
44376 318.86 302.92 348.36
44377 338.58 321.65 369.90
45170 749.39 711.92 818.71
45190 656.36 623.54 717.07
43870 680.72 646.68 743.68 44378 433.94 412.24 474.08 45300 112.49 106.87 122.90
43880 1,542.96 1,465.81 1,685.68
43886 327.92 311.52 358.25
44379 460.65 437.62 503.26
44380 73.11 69.45 79.87
# 45300 49.75 47.26 54.35
45303 906.94 861.59 990.83
43887 307.85 292.46 336.33
43888 431.97 410.37 471.93
44382 87.83 83.44 95.96
44383 186.72 177.38 203.99
# 45303 83.84 79.65 91.60
45305 183.55 174.37 200.53
44005 1,055.07 1,002.32 1,152.67
44010 831.78 790.19 908.72
44385 267.08 253.73 291.79
# 44385 110.68 105.15 120.92
# 45305 76.19 72.38 83.24
45307 202.21 192.10 220.92
44015 142.98 135.83 156.20 44386 374.34 355.62 408.96 # 45307 95.29 90.53 104.11
44020 933.40 886.73 1,019.74
44021 945.02 897.77 1,032.44
# 44386 130.02 123.52 142.05
44388 367.90 349.51 401.94
45308 186.39 177.07 203.63
# 45308 81.24 77.18 88.76
44025 950.31 902.79 1,038.21
44050 900.49 855.47 983.79
# 44388 172.62 163.99 188.59
44389 428.43 407.01 468.06
45309 210.26 199.75 229.71
# 45309 95.39 90.62 104.21
44055 1,436.13 1,364.32 1,568.97 # 44389 192.94 183.29 210.78 45315 225.24 213.98 246.08
44100 120.16 114.15 131.27
44110 815.17 774.41 890.57
44390 493.34 468.67 538.97
# 44390 230.90 219.36 252.26
# 45315 107.72 102.33 117.68
45317 215.96 205.16 235.93
44111 947.61 900.23 1,035.26
44120 1,170.88 1,112.34 1,279.19
44391 552.52 524.89 603.62
# 44391 263.58 250.40 287.96
# 45317 112.58 106.95 122.99
45320 219.04 208.09 239.30
44121 240.07 228.07 262.28
44125 1,138.40 1,081.48 1,243.70
44392 461.29 438.23 503.96
# 44392 226.69 215.36 247.66
# 45320 108.14 102.73 118.14
45321 104.38 99.16 114.03
44126 2,344.12 2,226.91 2,560.95 44393 533.28 506.62 582.61 45327 122.14 116.03 133.43
44127 2,727.93 2,591.53 2,980.26
44128 241.38 229.31 263.71
# 44393 288.96 274.51 315.69
44394 540.14 513.13 590.10
45330 145.72 138.43 159.19
# 45330 64.87 61.63 70.87
CODES: 43458 - 45330
# - These amounts apply when the service is performed in a facility setting.
C - The payment for the technical component is capped at the OPPS amount.
Limiting charge applies to unassigned claims by non-participating providers. All CPT codes and modifiers are bolded.
All Current Procedural Terminology (CPT) codes and descriptors are copyrighted 2008 by the American Medical Association..

45331
45331
45332
45332
45333
45333
45334
45335
45335
45337
45338
45338
45339
45339
45340
45340
45341
45342
45345
45355
45378
45378
4537853
4537853
45379
45379
45380
45380
45381
45381
45382
45382
45383
45383
45384
45384
45385
45385
45386
45386
45387
45391
45392
45395
45397
45400
45402
45500
45505
45520
45520
45540
45541
45550
45560
45562
45563
45800
45805
45820
45825
45900
45905
45910
45915
45915
45990
46020
46020
46030
46030
46040
46040
46045
46050
46050
46060
46070
46080
46080
46083
46083
46200
46200
46210
46210
46211
46211
46220
46220
46221
46221
46230
46230
46250
46250
46255
46255
46257
46258
46260
46261
46262
46270
46270
46275
46275
46280
46285
46285
46288
46320
46320
46500
46500
46505
46505
46600
46600
46604
46604
46606
46606
46608
46608
46610
46610
46611
46611
46612
46612
46614
46614
46615
46615
46700
46705
46706
46710
46712
46715
46716
46730
46735
46740
46742
46744
46746
46748
46750
46751
46753
46754
46754
46760
46761
46762
46900
46900
46910
46910
46916
46916
46917
46917
46922
46922
46924
46924
46930
46930
46937
46937
46938
46938
46940
46940
46942
46942
46945
46945
46946
46946
46947
47000
47000
47001
47010
47011
47015
47100
47120
47122
47125
47130
47135
47136
47140
47141
47142
47143
47144
47145
47146
47147
47300
47350
47360
47361
47362
47370
47371
47380
47381
47382
47400
47420
47425
47460
47480
47490
47500
47505
47510
47511
47525
47525
47530
47530
47550
47552






California - MEDICARE CARRIER 01192 FSY2009 LOCALITY 18 FEE SCHEDULE PAGE: 21
PROCEDURE PAR NONPAR LIMITING
CODE/MOD FEE FEE CHARGE
PROCEDURE
CODE/MOD
PAR
FEE
NONPAR
FEE
LIMITING
CHARGE
PROCEDURE
CODE/MOD
PAR
FEE
NONPAR LIMITING
FEE CHARGE
45331 185.84 176.55 203.03
# 45331 78.92 74.97 86.22
45332 306.01 290.71 334.32
# 45332 114.70 108.97 125.32
45333 307.93 292.53 336.41
# 45333 113.97 108.27 124.51
45334 172.80 164.16 188.78
45335 263.89 250.70 288.31
# 45335 95.56 90.78 104.40
45337 147.71 140.32 161.37
45338 341.22 324.16 372.78
# 45338 148.15 140.74 161.85
45339 348.99 331.54 381.27
# 45339 195.68 185.90 213.79
45340 475.60 451.82 519.59
# 45340 119.93 113.93 131.02
45341 164.98 156.73 180.24
45342 251.77 239.18 275.06
45345 183.02 173.87 199.95
45355 209.38 198.91 228.75
45378 422.93 401.78 462.05
# 45378 225.88 214.59 246.78
4537853 145.72 138.43 159.19
# 4537853 64.87 61.63 70.87
45379 536.94 510.09 586.60
# 45379 282.45 268.33 308.58
45380 507.84 482.45 554.82
# 45380 272.35 258.73 297.54
45381 495.17 470.41 540.97
# 45381 257.91 245.01 281.76
45382 670.50 636.98 732.53
# 45382 347.97 330.57 380.16
45383 600.20 570.19 655.72
# 45383 348.81 331.37 381.08
45384 496.38 471.56 542.29
# 45384 282.10 268.00 308.20
45385 570.37 541.85 623.13
# 45385 322.95 306.80 352.82
45386 717.93 682.03 784.33
# 45386 277.44 263.57 303.11
45387 362.24 344.13 395.75
45391 312.86 297.22 341.80
45392 395.13 375.37 431.68
45395 1,937.24 1,840.38 2,116.44
45397 2,092.79 1,988.15 2,286.37
45400 1,115.23 1,059.47 1,218.39
45402 1,487.53 1,413.15 1,625.12
45500 497.25 472.39 543.25
45505 546.65 519.32 597.22
45520 133.44 126.77 145.79
# 45520 38.89 36.95 42.49
45540 1,027.55 976.17 1,122.60
45541 888.77 844.33 970.98
45550 1,413.99 1,343.29 1,544.78
45560 705.42 670.15 770.67
45562 1,078.96 1,025.01 1,178.76
45563 1,559.29 1,481.33 1,703.53
45800 1,210.56 1,150.03 1,322.53
45805 1,364.73 1,296.49 1,490.96
45820 1,200.72 1,140.68 1,311.78
45825 1,447.67 1,375.29 1,581.58
45900 192.29 182.68 210.08
45905 164.74 156.50 179.98
45910 194.55 184.82 212.54
45915 312.91 297.26 341.85
# 45915 217.91 207.01 238.06
45990 106.53 101.20 116.38
46020 250.15 237.64 273.29
# 46020 216.57 205.74 236.60
46030 127.49 121.12 139.29
# 46030 85.52 81.24 93.43
46040 491.60 467.02 537.07
# 46040 388.22 368.81 424.13
46045 396.96 377.11 433.68
46050 181.15 172.09 197.90
# 46050 91.02 86.47 99.44
46060 437.95 416.05 478.46
46070
46080
# 46080
46083
# 46083
46200
# 46200
46210
# 46210
46211
# 46211
46220
# 46220
46221
# 46221
46230
# 46230
46250
# 46250
46255
# 46255
46257
46258
46260
46261
46262
46270
# 46270
46275
# 46275
46280
46285
# 46285
46288
46320
# 46320
46500
# 46500
46505
# 46505
46600
# 46600
46604
# 46604
46606
# 46606
46608
# 46608
46610
# 46610
46611
# 46611
46612
# 46612
46614
# 46614
46615
# 46615
46700
46705
46706
46710
46712
46715
46716
46730
46735
46740
46742
46744
46746
46748
46750
46751
46753
46754
# 46754
226.86
229.81
153.37
177.40
104.94
390.71
297.04
362.00
251.54
485.45
363.95
188.84
111.97
245.38
179.11
255.72
165.59
426.74
295.07
474.41
334.79
391.75
427.81
443.58
494.50
517.51
459.02
355.64
484.39
380.13
433.86
469.70
374.71
510.96
168.99
105.36
208.04
121.00
264.28
220.10
84.40
38.45
542.73
66.01
217.32
72.41
223.99
79.96
221.62
79.36
172.73
82.15
265.91
97.57
132.59
70.30
150.27
99.47
612.05
509.76
163.11
1,038.30
2,106.28
501.52
1,237.19
1,841.47
2,147.25
1,968.22
2,324.97
3,301.67
3,834.12
3,983.01
737.68
618.83
559.06
276.67
208.19
215.52
218.32
145.70
168.53
99.69
371.17
282.19
343.90
238.96
461.18
345.75
179.40
106.37
233.11
170.15
242.93
157.31
405.40
280.32
450.69
318.05
372.16
406.42
421.40
469.78
491.63
436.07
337.86
460.17
361.12
412.17
446.22
355.97
485.41
160.54
100.09
197.64
114.95
251.07
209.10
80.18
36.53
515.59
62.71
206.45
68.79
212.79
75.96
210.54
75.39
164.09
78.04
252.61
92.69
125.96
66.79
142.76
94.50
581.45
484.27
154.95
986.39
2,000.97
476.44
1,175.33
1,749.40
2,039.89
1,869.81
2,208.72
3,136.59
3,642.41
3,783.86
700.80
587.89
531.11
262.84
197.78
247.85
251.07
167.56
193.81
114.64
426.85
324.52
395.49
274.80
530.36
397.61
206.31
122.33
268.08
195.67
279.37
180.91
466.21
322.37
518.29
365.76
427.98
467.38
484.61
540.25
565.37
501.48
388.54
529.20
415.29
474.00
513.15
409.37
558.22
184.62
115.10
227.29
132.19
288.73
240.47
92.21
42.01
592.93
72.12
237.42
79.11
244.71
87.35
242.12
86.70
188.70
89.75
290.50
106.59
144.85
76.81
164.17
108.68
668.67
556.91
178.19
1,134.35
2,301.12
547.91
1,351.63
2,011.81
2,345.87
2,150.28
2,540.03
3,607.08
4,188.77
4,351.44
805.92
676.07
610.78
302.27
227.45
46760
46761
46762
46900
# 46900
46910
# 46910
46916
# 46916
46917
# 46917
46922
# 46922
46924
# 46924
46930
# 46930
46937
# 46937
46938
# 46938
46940
# 46940
46942
# 46942
46945
# 46945
46946
# 46946
46947
47000
# 47000
47001
47010
47011
47015
47100
47120
47122
47125
47130
47135
47136
47140
47141
47142
47143
47144
47145
47146
47147
47300
47350
47360
47361
47362
47370
47371
47380
47381
47382
47400
47420
47425
47460
47480
47490
47500
47505
47510
47511
47525
# 47525
47530
# 47530
47550
47552
1,042.18
899.16
888.57
226.86
135.40
237.36
129.11
235.04
143.58
465.03
130.13
247.95
129.10
522.36
179.07
219.61
155.55
249.91
170.82
436.28
354.54
209.91
141.87
195.14
126.22
277.23
210.07
298.08
219.44
363.07
361.11
107.07
102.89
1,153.29
207.22
1,093.42
806.07
2,247.41
3,332.51
2,986.64
3,210.12
4,729.93
4,038.93
3,368.46
4,002.91
4,401.31
316.88
475.31
475.31
326.22
380.63
1,076.30
1,318.88
1,789.13
2,931.95
1,367.03
1,204.19
1,229.50
1,406.04
1,434.91
891.52
2,036.75
1,291.15
1,303.58
1,235.09
825.81
561.68
110.20
42.51
529.71
659.80
678.86
141.17
1,624.01
397.97
164.75
356.54
990.07 1,138.58
854.20 982.33
844.14 970.76
215.52 247.85
128.63 147.92
225.49 259.31
122.65 141.05
223.29 256.78
136.40 156.86
441.78 508.05
123.62 142.16
235.55 270.88
122.65 141.05
496.24 570.68
170.12 195.64
208.63 239.92
147.77 169.94
237.41 273.02
162.28 186.62
414.47 476.64
336.81 387.33
199.41 229.32
134.78 155.00
185.38 213.19
119.91 137.90
263.37 302.88
199.57 229.51
283.18 325.66
208.47 239.74
344.92 396.66
343.05 394.51
101.72 116.98
97.75 112.41
1,095.63 1,259.97
196.86 226.39
1,038.75 1,194.56
765.77 880.64
2,135.04 2,455.30
3,165.88 3,640.76
2,837.31 3,262.91
3,049.61 3,507.05
4,493.43 5,167.44
3,836.98 4,412.53
3,200.04 3,680.05
3,802.76 4,373.17
4,181.24 4,808.43
301.04 346.20
451.54 519.27
451.54 519.27
309.91 356.40
361.60 415.84
1,022.49 1,175.86
1,252.94 1,440.88
1,699.67 1,954.62
2,785.35 3,203.15
1,298.68 1,493.48
1,143.98 1,315.58
1,168.03 1,343.23
1,335.74 1,536.10
1,363.16 1,567.63
846.94 973.98
1,934.91 2,225.15
1,226.59 1,410.58
1,238.40 1,424.16
1,173.34 1,349.34
784.52 902.20
533.60 613.64
104.69 120.39
40.38 46.44
503.22 578.70
626.81 720.83
644.92 741.66
134.11 154.23
1,542.81 1,774.23
378.07 434.78
156.51 179.99
338.71 389.52
CODES: 45331 - 47552
# - These amounts apply when the service is performed in a facility setting.
C - The payment for the technical component is capped at the OPPS amount.
Limiting charge applies to unassigned claims by non-participating providers. All CPT codes and modifiers are bolded.
All Current Procedural Terminology (CPT) codes and descriptors are copyrighted 2008 by the American Medical Association.

47553
47554
47555
47556
47560
47561
47562
47563
47564
47570
47600
47605
47610
47612
47620
47630
47700
47701
47711
47712
47715
47720
47721
47740
47741
47760
47765
47780
47785
47800
47801
47802
47900
48000
48001
48020
48100
48102
48102
48105
48120
48140
48145
48146
48148
48150
48152
48153
48154
48155
48400
48500
48510
48511
48511
48520
48540
48545
48547
48548
48551
48552
48554
48556
49000
49002
49010
49020
49021
49021
49040
49041
49041
49060
49061
49061
49062
49080
49080
49081
49081
49180
49180
49203
49204
49205
49215
49220
49250
49255
49320
49321
49322
49323
49324
49325
49326
49400
49400
49402
49419
49420
49421
49422
49423
49423
49424
49424
49425
49426
49427
49428
49429
49435
49436
49440
49440
49441
49441
49442
49442
49446
49446
49450
49450
49451
49451
49452
49452
49460
49460
49465
49465
49491
49492
49495
49496
49500
49501
49505
49507
49520
49521
49525
49540
49550
49553
49555
49557
49560
49561
49565
49566
49568
49570
49572
49580
49582
49585
49587
49590
49600
49605
49606
49610
49611
49650
49651
49652
49653
49654
49655
49656
49657
49900
49904
49905
50010
50020
50021
50021
50040
50045
50060
50065
50070
50075
50080
50081
50100
50120
50125
50130
50135
50200
50205
50220
50225
50230
50234
50236
50240
50250
50280
50290
50320
50323
50325
50327
50328
50329
50340
50360
50365
50370
50380
50382
50382
50384
50384
50385
50385
50386
50386
50387
50387
50389
50389
50390
50391
50391






California - MEDICARE CARRIER 01192 FSY2009 LOCALITY 18 FEE SCHEDULE PAGE: 22
PROCEDURE PAR NONPAR CHARGE
CODE/MOD FEE FEE LIMIT
PROCEDURE PAR NONPAR CHARGE
CODE/MOD FEE FEE LIMIT
PROCEDURE PAR NONPAR CHARGE
CODE/MOD FEE FEE LIMIT
47553 354.36 336.64 387.14
47554 520.49 494.47 568.64
49080 187.76 178.37 205.13
# 49080 75.54 71.76 82.52
49570 394.79 375.05 431.31
49572 486.33 462.01 531.31
47555 425.53 404.25 464.89 49081 175.39 166.62 191.61 49580 309.49 294.02 338.12
47556 481.31 457.24 525.83
47560 266.13 252.82 290.74
# 49081 71.12 67.56 77.69
49180 185.82 176.53 203.01
49582 455.45 432.68 497.58
49585 423.72 402.53 462.91
47561 289.68 275.20 316.48
47562 714.03 678.33 780.08
# 49180 97.01 92.16 105.98
49203 1,171.51 1,112.93 1,279.87
49587 500.32 475.30 546.60
49590 548.60 521.17 599.35
47563 729.88 693.39 797.40 49204 1,492.64 1,418.01 1,630.71 49600 707.50 672.13 772.95
47564 841.04 798.99 918.84
47570 751.81 714.22 821.35
49205 1,707.41 1,622.04 1,865.35
49215 2,140.51 2,033.48 2,338.50
49605 4,828.94 4,587.49 5,275.61
49606 1,098.92 1,043.97 1,200.57
47600 1,019.06 968.11 1,113.33
47605 944.23 897.02 1,031.57
49220 936.31 889.49 1,022.91
49250 562.76 534.62 614.81
49610 656.78 623.94 717.53
49611 595.61 565.83 650.70
47610 1,207.22 1,146.86 1,318.89
47612 1,219.14 1,158.18 1,331.91
49255 761.89 723.80 832.37
49320 322.62 306.49 352.46
49650 412.40 391.78 450.55
49651 532.08 505.48 581.30
47620 1,323.02 1,256.87 1,445.40 49321 339.31 322.34 370.69 49652 768.04 729.64 839.09
47630 599.95 569.95 655.44
47700 1,012.06 961.46 1,105.68
49322 368.07 349.67 402.12
49323 624.99 593.74 682.80
49653 958.64 910.71 1,047.32
49654 880.34 836.32 961.77
47701 1,737.95 1,651.05 1,898.71
47711 1,499.57 1,424.59 1,638.28
49324 382.49 363.37 417.88
49325 410.34 389.82 448.29
49655 1,059.62 1,006.64 1,157.64
49656 883.53 839.35 965.25
47712 1,915.89 1,820.10 2,093.12 49326 186.14 176.83 203.35 49657 1,272.75 1,209.11 1,390.48
47715 1,262.13 1,199.02 1,378.87
47720 1,092.59 1,037.96 1,193.65
49400 192.90 183.26 210.75
# 49400 104.98 99.73 114.69
49900 790.49 750.97 863.62
49904 1,478.91 1,404.96 1,615.70
47721 1,286.44 1,222.12 1,405.44
47740 1,243.23 1,181.07 1,358.23
49402 825.70 784.42 902.08
49419 445.60 423.32 486.82
49905 353.01 335.36 385.66
50010 773.55 734.87 845.10
47741 1,407.21 1,336.85 1,537.38
47760 2,105.07 1,999.82 2,299.79
49420 141.57 134.49 154.66
49421 383.23 364.07 418.68
50020 1,098.97 1,044.02 1,200.62
50021 1,069.86 1,016.37 1,168.83
47765 2,766.38 2,628.06 3,022.27 49422 381.48 362.41 416.77 # 50021 188.88 179.44 206.36
47780 2,298.66 2,183.73 2,511.29
47785 2,988.80 2,839.36 3,265.26
49423 647.25 614.89 707.12
# 49423 83.93 79.73 91.69
50040 1,038.74 986.80 1,134.82
50045 1,048.43 996.01 1,145.41
47800 1,514.11 1,438.40 1,654.16
47801 1,078.35 1,024.43 1,178.09
49424 173.28 164.62 189.31
# 49424 43.83 41.64 47.89
50060 1,289.15 1,224.69 1,408.39
50065 1,352.55 1,284.92 1,477.66
47802 1,454.99 1,382.24 1,589.58 49425 745.73 708.44 814.71 50070 1,347.35 1,279.98 1,471.98
47900 1,311.67 1,246.09 1,433.00
48000 1,811.64 1,721.06 1,979.22
49426 635.26 603.50 694.03
49427 50.47 47.95 55.14
50075 1,654.42 1,571.70 1,807.46
50080 986.92 937.57 1,078.21
48001 2,223.49 2,112.32 2,429.17
48020 1,122.22 1,066.11 1,226.03
49428 428.79 407.35 468.45
49429 450.94 428.39 492.65
50081 1,446.42 1,374.10 1,580.22
50100 1,050.64 998.11 1,147.83
48100 851.97 809.37 930.78
48102 593.84 564.15 648.77
49435 119.11 113.15 130.12
49436 180.25 171.24 196.93
50120 1,068.38 1,014.96 1,167.20
50125 1,104.29 1,049.08 1,206.44
# 48102 274.85 261.11 300.28 49440 1,250.06 1,187.56 1,365.69 50130 1,169.33 1,110.86 1,277.49
48105 2,738.45 2,601.53 2,991.76
48120 1,061.46 1,008.39 1,159.65
# 49440 255.54 242.76 279.17
49441 1,355.66 1,287.88 1,481.06
50135 1,264.60 1,201.37 1,381.58
50200 159.49 151.52 174.25
48140 1,501.06 1,426.01 1,639.91
48145 1,558.40 1,480.48 1,702.55
# 49441 281.17 267.11 307.18
49442 1,217.06 1,156.21 1,329.64
50205 740.14 703.13 808.60
50220 1,149.73 1,092.24 1,256.08
48146 1,783.52 1,694.34 1,948.49 # 49442 231.81 220.22 253.25 50225 1,329.89 1,263.40 1,452.91
48148 1,183.91 1,124.71 1,293.42
48150 3,001.38 2,851.31 3,279.01
49446 1,139.93 1,082.93 1,245.37
# 49446 186.05 176.75 203.26
50230 1,441.22 1,369.16 1,574.53
50234 1,464.34 1,391.12 1,599.79
48152 2,776.65 2,637.82 3,033.49
48153 2,996.80 2,846.96 3,274.00
49450 860.58 817.55 940.18
# 49450 74.15 70.44 81.01
50236 1,659.69 1,576.71 1,813.22
50240 1,490.73 1,416.19 1,628.62
48154 2,782.91 2,643.76 3,040.32
48155 1,731.91 1,645.31 1,892.11
49451 815.41 774.64 890.84
# 49451 103.64 98.46 113.23
50250 1,385.04 1,315.79 1,513.16
50280 1,064.18 1,010.97 1,162.62
48400 108.93 103.48 119.00 49452 1,023.18 972.02 1,117.82 50290 978.72 929.78 1,069.25
48500 1,087.49 1,033.12 1,188.09
48510 1,033.35 981.68 1,128.93
# 49452 161.64 153.56 176.59
49460 947.19 899.83 1,034.80
50320 1,455.00 1,382.25 1,589.59
50323 194.87 185.13 212.90
48511 1,059.40 1,006.43 1,157.39
# 48511 224.36 213.14 245.11
# 49460 52.96 50.31 57.86
49465 195.13 185.37 213.18
50325 194.87 185.13 212.90
50327 212.93 202.28 232.62
48520 1,049.66 997.18 1,146.76 # 49465 34.75 33.01 37.96 50328 187.11 177.75 204.41
48540 1,252.53 1,189.90 1,368.39
48545 1,268.57 1,205.14 1,385.91
49491 748.14 710.73 817.34
49492 912.65 867.02 997.07
50329 185.67 176.39 202.85
50340 896.05 851.25 978.94
48547 1,707.66 1,622.28 1,865.62
48548 1,602.16 1,522.05 1,750.36
49495 381.81 362.72 417.13
49496 579.33 550.36 632.91
50360 2,439.77 2,317.78 2,665.45
50365 2,747.49 2,610.12 3,001.64
48551 217.25 206.39 237.35
48552 227.43 216.06 248.47
49500 382.65 363.52 418.05
49501 574.86 546.12 628.04
50370 1,142.40 1,085.28 1,248.07
50380 1,947.19 1,849.83 2,127.30
48554 2,412.67 2,292.04 2,635.85 49505 499.36 474.39 545.55 50382 1,500.72 1,425.68 1,639.53
48556 1,196.67 1,136.84 1,307.37
49000 750.16 712.65 819.55
49507 612.62 581.99 669.29
49520 608.01 577.61 664.25
# 50382 313.12 297.46 342.08
50384 1,288.88 1,224.44 1,408.11
49002 975.22 926.46 1,065.43
49010 925.64 879.36 1,011.26
49521 739.47 702.50 807.88
49525 550.61 523.08 601.54
# 50384 285.08 270.83 311.45
50385 1,475.24 1,401.48 1,611.70
49020 1,531.16 1,454.60 1,672.79 49540 649.82 617.33 709.93 # 50385 269.52 256.04 294.45
49021 1,015.52 964.74 1,109.45
# 49021 189.32 179.85 206.83
49550 553.15 525.49 604.31
49553 604.66 574.43 660.59
50386 953.24 905.58 1,041.42
# 50386 203.92 193.72 222.78
49040 960.99 912.94 1,049.88
49041 1,032.89 981.25 1,128.44
49555 575.65 546.87 628.90
49557 697.25 662.39 761.75
50387 698.44 663.52 763.05
# 50387 113.47 107.80 123.97
# 49041 223.92 212.72 244.63
49060 1,075.46 1,021.69 1,174.94
49560 712.61 676.98 778.53
49561 896.11 851.30 979.00
50389 405.62 385.34 443.14
# 50389 62.33 59.21 68.09
49061 1,016.62 965.79 1,110.66 49565 738.79 701.85 807.13 50390 110.20 104.69 120.39
# 49061 207.22 196.86 226.39
49062 733.94 697.24 801.83
49566 905.41 860.14 989.16
49568 264.52 251.29 288.98
50391 145.69 138.41 159.17
# 50391 112.55 106.92 122.96
CODES: 47553 - 50391
# - These amounts apply when the service is performed in a facility setting.
C - The payment for the technical component is capped at the OPPS amount.
Limiting charge applies to unassigned claims by non-participating providers. All CPT codes and modifiers are bolded.
All Current Procedural Terminology (CPT) codes and descriptors are copyrighted 2008 by the American Medical Association..

50392
50393
50394
50394
50395
50396
50398
50398
50400
50405
50500
50520
50525
50526
50540
50541
50542
50543
50544
50545
50546
50547
50548
50551
50551
50553
50553
50555
50555
50557
50557
50561
50561
50562
50570
50572
50574
50575
50576
50580
50590
50590
50592
50592
50593
50593
50600
50605
50610
50620
50630
50650
50660
50684
50684
50686
50688
50690
50690
50700
50715
50722
50725
50727
50728
50740
50750
50760
50770
50780
50782
50783
50785
50800
50810
50815
50820
50825
50830
50840
50845
50860
50900
50920
50930
50940
50945
50947
50948
50951
50951
50953
50953
50955
50955
50957
50957
50961
50961
50970
50972
50974
50976
50980
51020
51030
51040
51045
51050
51060
51065
51080
51100
51100
51101
51101
51102
51102
51500
51520
51525
51530
51535
51550
51555
51565
51570
51575
51580
51585
51590
51595
51596
51597
51600
51600
51605
51610
51610
51700
51700
51701
51701
51702
51702
51703
51703
51705
51705
51710
51710
51715
51715
51720
51720
51725
5172526
51725TC
51726
5172626
51726TC
51736
5173626
51736TC
51741
5174126
51741TC
51772
5177226
51772TC
51784
5178426
51784TC
51785
5178526
51785TC
51792
5179226
51792TC
51795
5179526
51795TC
51797
5179726
51797TC
51798
51800
51820
51840
51841
51845
51860
51865
51880
51900
51920
51925
51940
51960
51980
51990
51992
52000
52000
52001
52001
52005
52005
52007
52007
52010
52010
52204
52204
52214
52214
52224
52224
52234
52235
52240
52250
52260
52265
52265
52270
52270
52275
52275
52276
52277






California - MEDICARE CARRIER 01192 FSY2009 LOCALITY 18 FEE SCHEDULE PAGE: 23
PROCEDURE PAR NONPAR LIMITING
CODE/MOD FEE FEE CHARGE
PROCEDURE
CODE/MOD
PAR
FEE
NONPAR
FEE
LIMITING
CHARGE
PROCEDURE
CODE/MOD
PAR
FEE
NONPAR LIMITING
FEE CHARGE
50392 203.90 193.71 222.77
50393 248.33 235.91 271.30
50394 122.32 116.20 133.63
# 50394 57.38 54.51 62.69
50395 205.52 195.24 224.53
50396 133.49 126.82 145.84
50398 629.14 597.68 687.33
# 50398 83.93 79.73 91.69
50400 1,300.86 1,235.82 1,421.19
50405 1,577.62 1,498.74 1,723.55
50500 1,254.36 1,191.64 1,370.39
50520 1,167.92 1,109.52 1,275.95
50525 1,453.63 1,380.95 1,588.09
50526 1,515.79 1,440.00 1,656.00
50540 1,272.25 1,208.64 1,389.94
50541 1,039.34 987.37 1,135.48
50542 1,319.31 1,253.34 1,441.34
50543 1,682.23 1,598.12 1,837.84
50544 1,415.21 1,344.45 1,546.12
50545 1,519.30 1,443.34 1,659.84
50546 1,350.30 1,282.79 1,475.21
50547 1,619.11 1,538.15 1,768.87
50548 1,530.95 1,454.40 1,672.56
50551 424.27 403.06 463.52
# 50551 337.23 320.37 368.43
50553 441.72 419.63 482.57
# 50553 355.56 337.78 388.45
50555 481.85 457.76 526.42
# 50555 389.51 370.03 425.53
50557 491.99 467.39 537.50
# 50557 395.67 375.89 432.27
50561 557.39 529.52 608.95
# 50561 451.80 429.21 493.59
50562 667.23 633.87 728.95
50570 563.53 535.35 615.65
50572 613.52 582.84 670.27
50574 647.40 615.03 707.28
50575 818.37 777.45 894.07
50576 646.56 614.23 706.36
50580 691.72 657.13 755.70
50590 1,086.81 1,032.47 1,187.34
# 50590 639.25 607.29 698.38
50592 4,323.40 4,107.23 4,723.31
# 50592 409.80 389.31 447.71
50593 5,577.78 5,298.89 6,093.72
# 50593 516.34 490.52 564.10
50600 1,054.71 1,001.97 1,152.27
50605 1,013.94 963.24 1,107.73
50610 1,078.34 1,024.42 1,178.08
50620 1,022.54 971.41 1,117.12
50630 995.42 945.65 1,087.50
50650 1,165.20 1,106.94 1,272.98
50660 1,286.61 1,222.28 1,405.62
50684 215.11 204.35 235.00
# 50684 56.94 54.09 62.20
50686 103.18 98.02 112.72
50688 90.96 86.41 99.37
50690 115.39 109.62 126.06
# 50690 79.60 75.62 86.96
50700 1,044.86 992.62 1,141.51
50715 1,226.34 1,165.02 1,339.77
50722 1,066.98 1,013.63 1,165.67
50725 1,223.65 1,162.47 1,336.84
50727 569.64 541.16 622.33
50728 778.65 739.72 850.68
50740 1,202.22 1,142.11 1,313.43
50750 1,310.47 1,244.95 1,431.69
50760 1,220.09 1,159.09 1,332.95
50770 1,263.46 1,200.29 1,380.33
50780 1,225.02 1,163.77 1,338.34
50782 1,202.01 1,141.91 1,313.20
50783 1,244.33 1,182.11 1,359.43
50785 1,358.81 1,290.87 1,484.50
50800 1,036.20 984.39 1,132.05
50810 1,354.21 1,286.50 1,479.48
50815 1,378.79 1,309.85 1,506.33
50820 1,465.00 1,391.75 1,600.51
50825
50830
50840
50845
50860
50900
50920
50930
50940
50945
50947
50948
50951
# 50951
50953
# 50953
50955
# 50955
50957
# 50957
50961
# 50961
50970
50972
50974
50976
50980
51020
51030
51040
51045
51050
51060
51065
51080
51100
# 51100
51101
# 51101
51102
# 51102
51500
51520
51525
51530
51535
51550
51555
51565
51570
51575
51580
51585
51590
51595
51596
51597
51600
# 51600
51605
51610
# 51610
51700
# 51700
51701
# 51701
51702
# 51702
51703
# 51703
51705
# 51705
51710
# 51710
51715
# 51715
51720
1,858.14
2,013.34
1,387.82
1,410.03
1,067.15
938.93
993.67
1,194.23
999.24
1,106.24
1,565.99
1,454.63
443.29
351.84
467.28
388.64
517.93
419.84
502.20
405.44
453.83
363.25
425.48
409.48
541.85
533.57
408.58
528.10
521.66
332.16
525.22
534.57
657.51
652.49
459.02
70.06
43.11
147.67
57.98
273.85
170.46
699.65
660.90
968.60
863.28
876.96
1,062.62
1,411.01
1,442.97
1,644.30
2,056.97
2,145.84
2,388.22
2,173.58
2,470.19
2,656.82
2,560.79
230.95
49.80
43.75
130.26
72.38
101.94
49.80
71.63
30.54
93.27
34.07
164.13
92.55
133.04
76.49
187.19
108.55
339.76
224.45
134.60
1,765.23
1,912.67
1,318.43
1,339.53
1,013.79
891.98
943.99
1,134.52
949.28
1,050.93
1,487.69
1,381.90
421.13
334.25
443.92
369.21
492.03
398.85
477.09
385.17
431.14
345.09
404.21
389.01
514.76
506.89
388.15
501.70
495.58
315.55
498.96
507.84
624.63
619.87
436.07
66.56
40.95
140.29
55.08
260.16
161.94
664.67
627.86
920.17
820.12
833.11
1,009.49
1,340.46
1,370.82
1,562.09
1,954.12
2,038.55
2,268.81
2,064.90
2,346.68
2,523.98
2,432.75
219.40
47.31
41.56
123.75
68.76
96.84
47.31
68.05
29.01
88.61
32.37
155.92
87.92
126.39
72.67
177.83
103.12
322.77
213.23
127.87
2,030.01
2,199.57
1,516.19
1,540.46
1,165.86
1,025.78
1,085.59
1,304.70
1,091.67
1,208.57
1,710.84
1,589.19
484.30
384.39
510.51
424.59
565.83
458.68
548.65
442.95
495.81
396.85
464.84
447.36
591.97
582.92
446.37
576.96
569.92
362.88
573.80
584.02
718.32
712.85
501.48
76.54
47.09
161.33
63.34
299.18
186.23
764.37
722.04
1,058.20
943.14
958.08
1,160.91
1,541.53
1,576.44
1,796.40
2,247.24
2,344.33
2,609.13
2,374.64
2,698.68
2,902.58
2,797.66
252.31
54.41
47.79
142.31
79.07
111.37
54.41
78.26
33.36
101.90
37.23
179.31
101.11
145.35
83.57
204.50
118.59
371.19
245.21
147.05
# 51720
51725
5172526
51725 TC
51726
5172626
51726 TC
51736
5173626
51736 TC
51741
5174126
51741 TC
51772
5177226
51772 TC
51784
5178426
51784 TC
51785
5178526
51785 TC
51792
5179226
51792 TC
51795
5179526
51795 TC
51797
5179726
51797 TC
51798
51800
51820
51840
51841
51845
51860
51865
51880
51900
51920
51925
51940
51960
51980
51990
51992
52000
# 52000
52001
# 52001
52005
# 52005
52007
# 52007
52010
# 52010
52204
# 52204
52214
# 52214
52224
# 52224
52234
52235
52240
52250
52260
52265
# 52265
52270
# 52270
52275
# 52275
52276
52277
94.40
261.92
85.36
176.56
384.44
97.13
287.30
62.20
34.96
27.24
97.24
65.29
31.95
293.78
90.42
203.36
239.25
86.11
153.14
260.61
86.26
174.35
276.84
61.89
214.96
362.93
86.55
276.38
179.00
49.86
129.13
25.29
1,175.74
1,195.25
716.25
848.33
654.59
798.59
987.93
520.44
916.73
848.41
1,105.11
1,797.43
1,560.70
803.04
821.36
893.66
246.40
142.13
443.97
327.78
344.86
151.79
655.25
189.57
482.65
183.10
536.04
160.49
702.26
250.73
1,017.62
193.64
282.00
330.43
576.32
277.27
238.87
509.54
179.94
487.89
208.22
666.79
284.62
303.98
370.84
89.68 103.13
248.82 286.14
81.09 93.25
167.73 192.89
365.22 420.00
92.27 106.11
272.94 313.88
59.09 67.95
33.21 38.19
25.88 29.76
92.38 106.24
62.03 71.33
30.35 34.90
279.09 320.95
85.90 98.79
193.19 222.17
227.29 261.38
81.80 94.07
145.48 167.30
247.58 284.72
81.95 94.24
165.63 190.47
263.00 302.45
58.80 67.62
204.21 234.84
344.78 396.50
82.22 94.55
262.56 301.94
170.05 195.56
47.37 54.48
122.67 141.07
24.03 27.63
1,116.95 1,284.49
1,135.49 1,305.81
680.44 782.51
805.91 926.80
621.86 715.14
758.66 872.46
938.53 1,079.31
494.42 568.58
870.89 1,001.52
805.99 926.89
1,049.85 1,207.33
1,707.56 1,963.69
1,482.67 1,705.07
762.89 877.32
780.29 897.33
848.98 976.33
234.08 269.19
135.02 155.27
421.77 485.04
311.39 358.10
327.62 376.76
144.20 165.83
622.49 715.86
180.09 207.10
458.52 527.30
173.95 200.04
509.24 585.63
152.47 175.34
667.15 767.22
238.19 273.92
966.74 1,111.75
183.96 211.55
267.90 308.09
313.91 361.00
547.50 629.63
263.41 302.92
226.93 260.97
484.06 556.67
170.94 196.58
463.50 533.03
197.81 227.48
633.45 728.47
270.39 310.95
288.78 332.10
352.30 405.15
CODES: 50392 - 52277
# - These amounts apply when the service is performed in a facility setting.
C - The payment for the technical component is capped at the OPPS amount.
Limiting charge applies to unassigned claims by non-participating providers. All CPT codes and modifiers are bolded.
All Current Procedural Terminology (CPT) codes and descriptors are copyrighted 2008 by the American Medical Association.

52281
52281
52282
52283
52283
52285
52285
52290
52300
52301
52305
52310
52310
52315
52315
52317
52317
52318
52320
52325
52327
52327
52330
52330
52332
52332
52334
52341
52342
52343
52344
52345
52346
52351
52352
52353
52354
52355
52400
52402
52450
52500
52601
52630
52640
52647
52647
52648
52648
52649
52700
53000
53010
53020
53025
53040
53060
53060
53080
53085
53200
53200
53210
53215
53220
53230
53235
53240
53250
53260
53260
53265
53265
53270
53270
53275
53400
53405
53410
53415
53420
53425
53430
53431
53440
53442
53444
53445
53446
53447
53448
53449
53450
53460
53500
53502
53505
53510
53515
53520
53600
53600
53601
53601
53605
53620
53620
53621
53621
53660
53660
53661
53661
53665
53850
53850
53852
53852
54000
54000
54001
54001
54015
54050
54050
54055
54055
54056
54056
54057
54057
54060
54060
54065
54065
54100
54100
54105
54105
54110
54111
54112
54115
54115
54120
54125
54130
54135
54150
54150
54160
54160
54161
54162
54162
54163
54164
54200
54200
54205
54220
54220
54230
54230
54231
54231
54235
54235
54240
5424026
54240TC
54250
5425026
54250TC
54300
54304
54308
54312
54316
54318
54322
54324
54326
54328
54332
54336
54340
54344
54348
54352
54360
54380
54385
54390
54400
54401
54405
54406
54408
54410
54411
54415
54416
54417
54420
54430
54435
54440
54450
54450
54500
54505
54512
54520
54522
54530
54535
54550
54560
54600
54620
54640
54650
54660
54670
54680
54690
54692
54700
54800
54830






California - MEDICARE CARRIER 01192 FSY2009 LOCALITY 18 FEE SCHEDULE PAGE: 24
PROCEDURE PAR NONPAR CHARGE
CODE/MOD FEE FEE LIMIT
PROCEDURE PAR NONPAR CHARGE
CODE/MOD FEE FEE LIMIT
PROCEDURE PAR NONPAR CHARGE
CODE/MOD FEE FEE LIMIT
52281 364.97 346.72 398.73
# 52281 176.76 167.92 193.11
53405 995.51 945.73 1,087.59
53410 1,109.32 1,053.85 1,211.93
# 54162 222.53 211.40 243.11
54163 249.04 236.59 272.08
52282 382.42 363.30 417.80 53415 1,276.96 1,213.11 1,395.08 54164 220.12 209.11 240.48
52283 328.73 312.29 359.13
# 52283 228.88 217.44 250.06
53420 904.00 858.80 987.62
53425 1,068.19 1,014.78 1,167.00
54200 129.91 123.41 141.92
# 54200 97.65 92.77 106.69
52285 332.24 315.63 362.97
# 52285 221.79 210.70 242.31
53430 1,062.40 1,009.28 1,160.67
53431 1,304.98 1,239.73 1,425.69
54205 609.69 579.21 666.09
54220 249.10 236.65 272.15
52290 279.76 265.77 305.64 53440 992.14 942.53 1,083.91 # 54220 152.78 145.14 166.91
52300 320.91 304.86 350.59
52301 337.80 320.91 369.05
53442 875.32 831.55 956.28
53444 901.53 856.45 984.92
54230 113.01 107.36 123.46
# 54230 91.36 86.79 99.81
52305 318.70 302.77 348.19
52310 297.31 282.44 324.81
53445 997.85 947.96 1,090.15
53446 731.07 694.52 798.70
54231 162.97 154.82 178.04
# 54231 134.25 127.54 146.67
# 52310 173.16 164.50 189.18
52315 524.51 498.28 573.02
53447 921.99 875.89 1,007.27
53448 1,450.51 1,377.98 1,584.68
54235 104.88 99.64 114.59
# 54235 84.11 79.90 91.89
# 52315 314.21 298.50 343.28 53449 694.52 659.79 758.76 54240 118.18 112.27 129.11
52317 1,150.36 1,092.84 1,256.77
# 52317 397.95 378.05 434.76
53450 463.92 440.72 506.83
53460 519.98 493.98 568.08
5424026 75.35 71.58 82.32
54240TC 42.83 40.69 46.79
52318 542.01 514.91 592.15
52320 281.97 267.87 308.05
53500 831.83 790.24 908.78
53502 549.23 521.77 600.04
54250 142.91 135.76 156.12
5425026 127.75 121.36 139.56
52325 366.49 348.17 400.40 53505 552.21 524.60 603.29 54250TC 15.16 14.40 16.56
52327 631.12 599.56 689.49
# 52327 298.88 283.94 326.53
53510 717.02 681.17 783.35
53515 900.98 855.93 984.32
54300 736.77 699.93 804.92
54304 861.65 818.57 941.36
52330 938.89 891.95 1,025.74
# 52330 301.79 286.70 329.71
53520 630.29 598.78 688.60
53600 99.73 94.74 108.95
54308 820.68 779.65 896.60
54312 948.88 901.44 1,036.66
52332 582.88 553.74 636.80
# 52332 178.62 169.69 195.14
# 53600 73.22 69.56 79.99
53601 98.47 93.55 107.58
54316 1,144.10 1,086.90 1,249.94
54318 829.19 787.73 905.89
52334 293.62 278.94 320.78 # 53601 61.36 58.29 67.03 54322 896.16 851.35 979.05
52341 334.84 318.10 365.82
52342 363.76 345.57 397.41
53605 73.20 69.54 79.97
53620 143.54 136.36 156.81
54324 1,112.26 1,056.65 1,215.15
54326 1,041.12 989.06 1,137.42
52343 404.30 384.09 441.70
52344 438.81 416.87 479.40
# 53620 99.80 94.81 109.03
53621 137.09 130.24 149.78
54328 1,058.98 1,006.03 1,156.93
54332 1,158.33 1,100.41 1,265.47
52345 467.73 444.34 510.99 # 53621 82.75 78.61 90.40 54336 1,307.78 1,242.39 1,428.75
52346 527.43 501.06 576.22
52351 359.66 341.68 392.93
53660 86.43 82.11 94.43
# 53660 47.11 44.75 51.46
54340 639.95 607.95 699.14
54344 1,099.71 1,044.72 1,201.43
52352 422.36 401.24 461.43
52353 485.49 461.22 530.40
53661 85.92 81.62 93.86
# 53661 46.16 43.85 50.43
54348 1,165.87 1,107.58 1,273.72
54352 1,640.86 1,558.82 1,792.64
52354 448.90 426.46 490.43
52355 534.61 507.88 584.06
53665 42.65 40.52 46.60
53850 3,048.12 2,895.71 3,330.07
54360 826.69 785.36 903.16
54380 916.02 870.22 1,000.75
52400 552.07 524.47 603.14 # 53850 642.87 610.73 702.34 54385 1,111.79 1,056.20 1,214.63
52402 306.22 290.91 334.55
52450 531.43 504.86 580.59
53852 2,925.49 2,779.22 3,196.10
# 53852 701.39 666.32 766.27
54390 1,328.88 1,262.44 1,451.81
54400 606.82 576.48 662.95
52500 555.08 527.33 606.43
52601 930.39 883.87 1,016.45
54000 184.59 175.36 201.66
# 54000 122.73 116.59 134.08
54401 748.79 711.35 818.05
54405 918.18 872.27 1,003.11
52630 501.71 476.62 548.11 54001 224.73 213.49 245.51 54406 829.19 787.73 905.89
52640 346.30 328.99 378.34
52647 2,636.51 2,504.68 2,880.38
# 54001 156.69 148.86 171.19
54015 351.19 333.63 383.67
54408 892.84 848.20 975.43
54410 980.34 931.32 1,071.02
# 52647 730.07 693.57 797.61
52648 2,688.27 2,553.86 2,936.94
54050 138.43 131.51 151.24
# 54050 108.39 102.97 118.42
54411 1,156.98 1,099.13 1,264.00
54415 598.94 568.99 654.34
# 52648 778.30 739.39 850.30
52649 1,112.54 1,056.91 1,215.45
54055 132.00 125.40 144.21
# 54055 99.31 94.34 108.49
54416 801.56 761.48 875.70
54417 1,014.94 964.19 1,108.82
52700 490.64 466.11 536.03 54056 144.92 137.67 158.32 54420 804.55 764.32 878.97
53000 169.64 161.16 185.33
53010 333.75 317.06 364.62
# 54056 112.23 106.62 122.61
54057 160.37 152.35 175.20
54430 730.36 693.84 797.92
54435 475.59 451.81 519.58
53020 110.87 105.33 121.13
53025 73.02 69.37 79.78
# 54057 104.70 99.47 114.39
54060 214.83 204.09 234.70
54440 1,366.64 1,298.31 1,493.06
54450 84.13 79.92 91.91
53040 444.93 422.68 486.08 # 54060 144.58 137.35 157.95 # 54450 66.46 63.14 72.61
53060 197.30 187.44 215.56
# 53060 172.56 163.93 188.52
54065 233.23 221.57 254.81
# 54065 176.23 167.42 192.53
54500 86.10 81.80 94.07
54505 243.26 231.10 265.77
53080 496.02 471.22 541.90
53085 692.06 657.46 756.08
54100 216.50 205.68 236.53
# 54100 130.35 123.83 142.40
54512 606.76 576.42 662.88
54520 370.22 351.71 404.47
53200 176.38 167.56 192.69
# 53200 159.15 151.19 173.87
54105 321.06 305.01 350.76
# 54105 245.07 232.82 267.74
54522 657.40 624.53 718.21
54530 576.52 547.69 629.84
53210 868.74 825.30 949.10 54110 705.66 670.38 770.94 54535 829.81 788.32 906.57
53215 1,053.75 1,001.06 1,151.22
53220 510.32 484.80 557.52
54111 909.42 863.95 993.54
54112 1,067.01 1,013.66 1,165.71
54550 553.99 526.29 605.23
54560 750.32 712.80 819.72
53230 678.21 644.30 740.95
53235 722.43 686.31 789.26
54115 515.06 489.31 562.71
# 54115 477.95 454.05 522.16
54600 513.49 487.82 560.99
54620 344.08 326.88 375.91
53240 487.45 463.08 532.54 54120 714.07 678.37 780.13 54640 528.85 502.41 577.77
53250 452.74 430.10 494.62
53260 226.80 215.46 247.78
54125 917.48 871.61 1,002.35
54130 1,355.68 1,287.90 1,481.09
54650 804.67 764.44 879.11
54660 404.78 384.54 442.22
# 53260 198.09 188.19 216.42
53265 253.42 240.75 276.86
54135 1,717.32 1,631.45 1,876.17
54150 196.59 186.76 214.77
54670 460.00 437.00 502.55
54680 885.49 841.22 967.40
# 53265 208.35 197.93 227.62
53270 230.62 219.09 251.95
# 54150 109.11 103.65 119.20
54160 273.45 259.78 298.75
54690 712.08 676.48 777.95
54692 875.43 831.66 956.41
# 53270 203.67 193.49 222.51 # 54160 164.32 156.10 179.52 54700 239.78 227.79 261.96
53275 300.79 285.75 328.61
53400 904.54 859.31 988.21
54161 223.86 212.67 244.57
54162 314.43 298.71 343.52
54800 150.26 142.75 164.16
54830 419.34 398.37 458.13
CODES: 52281 - 54830
# - These amounts apply when the service is performed in a facility setting.
C - The payment for the technical component is capped at the OPPS amount.
Limiting charge applies to unassigned claims by non-participating providers. All CPT codes and modifiers are bolded.
All Current Procedural Terminology (CPT) codes and descriptors are copyrighted 2008 by the American Medical Association..

54840
54860
54861
54865
54900
54901
55000
55000
55040
55041
55060
55100
55100
55110
55120
55150
55175
55180
55200
55200
55250
55250
55300
55400
55450
55450
55500
55520
55530
55535
55540
55550
55600
55605
55650
55680
55700
55700
55705
55706
55720
55725
55801
55810
55812
55815
55821
55831
55840
55842
55845
55860
55862
55865
55866
55870
55870
55873
55875
55876
55876
55920
56405
56405
56420
56420
56440
56441
56441
56442
56501
56501
56515
56515
56605
56605
56606
56606
56620
56625
56630
56631
56632
56633
56634
56637
56640
56700
56740
56800
56805
56810
56820
56820
56821
56821
57000
57010
57020
57020
57022
57023
57061
57061
57065
57065
57100
57100
57105
57105
57106
57107
57109
57110
57111
57112
57120
57130
57130
57135
57135
57150
57150
57155
57160
57160
57170
57170
57180
57180
57200
57210
57220
57230
57240
57250
57260
57265
57267
57268
57270
57280
57282
57283
57284
57285
57287
57288
57289
57291
57292
57295
57296
57300
57305
57307
57308
57310
57311
57320
57330
57335
57400
57410
57415
57420
57420
57421
57421
57423
57425
57452
57452
57454
57454
57455
57455
57456
57456
57460
57460
57461
57461
57500
57500
57505
57505
57510
57510
57511
57511
57513
57513
57520
57520
57522
57522
57530
57531
57540
57545
57550
57555
57556
57558
57558
57700
57720
57800
57800
58100
58100
58110
58110
58120
58120
58140
58145
58146
58150
58152
58180
58200
58210
58240
58260
58262
58263
58267
58270
58275






California - MEDICARE CARRIER 01192 FSY2009 LOCALITY 18 FEE SCHEDULE PAGE: 25
PROCEDURE PAR NONPAR LIMITING
CODE/MOD FEE FEE CHARGE
PROCEDURE
CODE/MOD
PAR
FEE
NONPAR
FEE
LIMITING
CHARGE
PROCEDURE
CODE/MOD
PAR
FEE
NONPAR LIMITING
FEE CHARGE
54840 367.98 349.58 402.02
54860 474.35 450.63 518.22
54861 639.13 607.17 698.25
54865 405.18 384.92 442.66
54900 847.85 805.46 926.28
54901 1,215.84 1,155.05 1,328.31
55000 141.71 134.62 154.81
# 55000 95.76 90.97 104.62
55040 382.73 363.59 418.13
55041 573.50 544.83 626.55
55060 427.82 406.43 467.39
55100 251.44 238.87 274.70
# 55100 182.96 173.81 199.88
55110 434.59 412.86 474.79
55120 399.48 379.51 436.44
55150 549.81 522.32 600.67
55175 409.84 389.35 447.75
55180 774.23 735.52 845.85
55200 579.69 550.71 633.32
# 55200 313.28 297.62 342.26
55250 516.28 490.47 564.04
# 55250 259.58 246.60 283.59
55300 202.72 192.58 221.47
55400 572.54 543.91 625.50
55450 445.90 423.61 487.15
# 55450 288.17 273.76 314.82
55500 423.34 402.17 462.50
55520 433.28 411.62 473.36
55530 401.20 381.14 438.31
55535 483.50 459.33 528.23
55540 523.34 497.17 571.75
55550 477.94 454.04 522.15
55600 483.74 459.55 528.48
55605 567.90 539.51 620.44
55650 806.46 766.14 881.06
55680 384.33 365.11 419.88
55700 270.60 257.07 295.63
# 55700 153.96 146.26 168.20
55705 306.27 290.96 334.60
55706 436.17 414.36 476.51
55720 525.38 499.11 573.98
55725 665.92 632.62 727.51
55801 1,228.36 1,166.94 1,341.98
55810 1,482.92 1,408.77 1,620.09
55812 1,822.31 1,731.19 1,990.87
55815 1,997.67 1,897.79 2,182.46
55821 989.46 939.99 1,080.99
55831 1,071.38 1,017.81 1,170.48
55840 1,514.73 1,438.99 1,654.84
55842 1,622.51 1,541.38 1,772.59
55845 1,852.89 1,760.25 2,024.29
55860 992.31 942.69 1,084.09
55862 1,253.45 1,190.78 1,369.40
55865 1,516.59 1,440.76 1,656.87
55866 1,970.06 1,871.56 2,152.29
55870 202.24 192.13 220.95
# 55870 163.80 155.61 178.95
55873 1,295.14 1,230.38 1,414.94
55875 863.53 820.35 943.40
55876 165.41 157.14 180.71
# 55876 121.67 115.59 132.93
55920 479.92 455.92 524.31
56405 113.65 107.97 124.17
# 56405 111.00 105.45 121.27
56420 133.13 126.47 145.44
# 56420 95.13 90.37 103.93
56440 189.25 179.79 206.76
# 56441 148.55 141.12 162.29
56441 157.83 149.94 172.43
56442 51.27 48.71 56.02
56501 137.64 130.76 150.37
# 56501 118.20 112.29 129.13
56515 232.02 220.42 253.48
# 56515 202.86 192.72 221.63
56605 87.93 83.53 96.06
# 56605 62.30 59.19 68.07
56606 40.35 38.33 44.08
# 56606
56620
56625
56630
56631
56632
56633
56634
56637
56640
56700
56740
56800
56805
56810
56820
# 56820
56821
# 56821
57000
57010
57020
# 57020
57022
57023
57061
# 57061
57065
# 57065
57100
# 57100
57105
# 57105
57106
57107
57109
57110
57111
57112
57120
57130
# 57130
57135
# 57135
57150
# 57150
57155
57160
# 57160
57170
# 57170
57180
# 57180
57200
57210
57220
57230
57240
57250
57260
57265
57267
57268
57270
57280
57282
57283
57284
57285
57287
57288
57289
57291
57292
57295
57296
57300
30.63
511.48
610.37
887.36
1,128.00
1,307.45
1,155.13
1,221.09
1,440.43
1,435.21
192.54
304.94
251.53
1,174.55
269.58
116.32
87.16
155.35
118.24
197.24
443.30
97.77
83.63
171.21
320.32
120.51
101.52
200.96
176.66
92.85
67.23
142.90
130.53
489.32
1,429.09
1,631.19
922.59
1,650.79
1,750.02
527.33
189.71
167.18
202.83
179.86
54.49
30.63
437.06
82.26
49.13
73.14
49.73
151.29
111.09
307.95
380.02
331.28
412.66
678.70
661.90
823.97
921.81
277.33
497.33
817.52
993.48
528.05
706.03
862.20
687.60
732.22
766.23
804.46
560.56
852.16
510.50
970.68
546.63
29.10
485.91
579.85
842.99
1,071.60
1,242.08
1,097.37
1,160.04
1,368.41
1,363.45
182.91
289.69
238.95
1,115.82
256.10
110.50
82.80
147.58
112.33
187.38
421.14
92.88
79.45
162.65
304.30
114.48
96.44
190.91
167.83
88.21
63.87
135.76
124.00
464.85
1,357.64
1,549.63
876.46
1,568.25
1,662.52
500.96
180.22
158.82
192.69
170.87
51.77
29.10
415.21
78.15
46.67
69.48
47.24
143.73
105.54
292.55
361.02
314.72
392.03
644.77
628.81
782.77
875.72
263.46
472.46
776.64
943.81
501.65
670.73
819.09
653.22
695.61
727.92
764.24
532.53
809.55
484.98
922.15
519.30
33.47
558.80
666.83
969.44
1,232.34
1,428.39
1,261.98
1,334.05
1,573.67
1,567.97
210.35
333.14
274.79
1,283.19
294.52
127.08
95.22
169.72
129.18
215.49
484.31
106.81
91.37
187.05
349.95
131.65
110.91
219.55
193.00
101.44
73.45
156.12
142.60
534.58
1,561.29
1,782.07
1,007.93
1,803.49
1,911.90
576.10
207.25
182.64
221.59
196.50
59.54
33.47
477.49
89.87
53.67
79.90
54.33
165.29
121.37
336.43
415.17
361.93
450.83
741.49
723.13
900.19
1,007.08
302.98
543.33
893.14
1,085.38
576.90
771.34
941.95
751.20
799.95
837.11
878.88
612.41
930.98
557.73
1,060.47
597.20
57305
57307
57308
57310
57311
57320
57330
57335
57400
57410
57415
57420
# 57420
57421
# 57421
57423
57425
57452
# 57452
57454
# 57454
57455
# 57455
57456
# 57456
57460
# 57460
57461
# 57461
57500
# 57500
57505
# 57505
57510
# 57510
# 57511
57511
57513
# 57513
57520
# 57520
57522
# 57522
57530
57531
57540
57545
57550
57555
57556
57558
# 57558
57700
57720
57800
# 57800
58100
# 58100
58110
# 58110
58120
# 58120
58140
58145
58146
58150
58152
58180
58200
58210
58240
58260
58262
58263
58267
58270
58275
906.44
1,014.38
650.53
513.85
585.11
582.94
822.95
1,194.03
140.04
110.25
165.73
122.13
92.53
164.21
126.22
949.45
1,000.81
115.00
95.12
160.99
141.11
151.04
114.37
142.99
106.77
322.44
169.13
359.81
194.13
143.08
77.25
107.70
95.33
138.98
119.98
136.63
152.54
150.33
137.52
323.05
283.28
275.49
251.19
355.71
1,734.00
797.33
840.54
419.83
615.33
588.63
131.11
117.41
319.22
317.28
63.77
50.52
115.68
90.50
50.96
42.57
260.42
221.54
933.02
556.84
1,186.68
1,009.51
1,274.36
969.70
1,332.91
1,774.69
2,785.35
845.84
944.01
1,016.68
1,079.81
904.79
1,006.97
861.12 990.29
963.66 1,108.21
618.00 710.70
488.16 561.38
555.85 639.23
553.79 636.86
781.80 899.07
1,134.33 1,304.48
133.04 153.00
104.74 120.45
157.44 181.06
116.02 133.42
87.90 101.09
156.00 179.40
119.91 137.90
901.98 1,037.28
950.77 1,093.39
109.25 125.64
90.36 103.91
152.94 175.88
134.05 154.16
143.49 165.01
108.65 124.95
135.84 156.22
101.43 116.64
306.32 352.27
160.67 184.77
341.82 393.09
184.42 212.08
135.93 156.32
73.39 84.40
102.32 117.67
90.56 104.14
132.03 151.83
113.98 131.08
129.80 149.27
144.91 166.65
142.81 164.23
130.64 150.24
306.90 352.94
269.12 309.49
261.72 300.98
238.63 274.42
337.92 388.61
1,647.30 1,894.40
757.46 871.08
798.51 918.29
398.84 458.67
584.56 672.24
559.20 643.08
124.55 143.23
111.54 128.27
303.26 348.75
301.42 346.63
60.58 69.67
47.99 55.19
109.90 126.39
85.98 98.88
48.41 55.67
40.44 46.51
247.40 284.51
210.46 242.03
886.37 1,019.33
529.00 608.35
1,127.35 1,296.45
959.03 1,102.88
1,210.64 1,392.24
921.22 1,059.40
1,266.26 1,456.20
1,685.96 1,938.85
2,646.08 3,042.99
803.55 924.08
896.81 1,031.33
965.85 1,110.73
1,025.82 1,179.69
859.55 988.48
956.62 1,100.11
CODES: 54840 - 58275
# - These amounts apply when the service is performed in a facility setting.
C - The payment for the technical component is capped at the OPPS amount.
Limiting charge applies to unassigned claims by non-participating providers. All CPT codes and modifiers are bolded.
All Current Procedural Terminology (CPT) codes and descriptors are copyrighted 2008 by the American Medical Association.

58280
58285
58290
58291
58292
58293
58294
58301
58301
58321
58321
58322
58322
58323
58323
58340
58340
58345
58346
58350
58350
58353
58353
58356
58356
58400
58410
58520
58540
58541
58542
58543
58544
58545
58546
58548
58550
58552
58553
58554
58555
58555
58558
58558
58559
58560
58561
58562
58562
58563
58563
58565
58565
58570
58571
58572
58573
58600
58605
58611
58615
58660
58661
58662
58670
58671
58672
58673
58700
58720
58740
58750
58752
58760
58770
58800
58800
58805
58820
58822
58823
58823
58825
58900
58920
58925
58940
58943
58950
58951
58952
58953
58954
58956
58957
58958
58960
58970
58970
58976
58976
59000
59000
59001
59012
59015
59015
59020
5902026
59020TC
59025
5902526
59025TC
59030
59050
59051
59070
59070
59072
59074
59074
59076
59100
59120
59121
59130
59135
59136
59140
59150
59151
59160
59160
59200
59200
59300
59300
59320
59325
59350
59400
59409
59410
59412
59414
59425
59425
59426
59426
59430
59430
59510
59514
59515
59525
59610
59612
59614
59618
59620
59622
59812
59812
59820
59820
59821
59821
59830
59840
59840
59841
59841
59850
59851
59852
59855
59856
59857
59866
59870
59871
60000
60000
60100
60100
60200
60210
60212
60220
60225
60240
60252
60254
60260
60270
60271
60280
60281
60300
60300
60500
60502
60505
60512
60520
60521
60522
60540
60545
60600
60605
60650
61000
61001
61020
61026
61050
61055
61070
61105
61107
61108
61120
61140
61150
61151
61154
61156
61210
61215
61250






California - MEDICARE CARRIER 01192 FSY2009 LOCALITY 18 FEE SCHEDULE PAGE: 26
PROCEDURE PAR NONPAR CHARGE
CODE/MOD FEE FEE LIMIT
PROCEDURE PAR NONPAR CHARGE
CODE/MOD FEE FEE LIMIT
PROCEDURE PAR NONPAR CHARGE
CODE/MOD FEE FEE LIMIT
58280 1,076.48 1,022.66 1,176.06
58285 1,347.05 1,279.70 1,471.66
58805 417.10 396.25 455.69
58820 324.18 307.97 354.17
59525 496.98 472.13 542.95
59610 1,911.97 1,816.37 2,088.83
58290 1,180.97 1,121.92 1,290.21 58822 722.48 686.36 789.31 59612 884.39 840.17 966.20
58291 1,283.12 1,218.96 1,401.80
58292 1,351.37 1,283.80 1,476.37
# 58823 188.71 179.27 206.16
58823 1,027.72 976.33 1,122.78
59614 992.81 943.17 1,084.65
59618 2,150.53 2,043.00 2,349.45
58293 1,402.40 1,332.28 1,532.12
58294 1,246.51 1,184.18 1,361.81
58825 713.04 677.39 779.00
58900 425.25 403.99 464.59
59620 1,025.82 974.53 1,120.71
59622 1,201.49 1,141.42 1,312.63
58301 101.52 96.44 110.91 58920 717.32 681.45 783.67 59812 324.92 308.67 354.97
# 58301 69.70 66.22 76.15
58321 83.83 79.64 91.59
58925 748.14 710.73 817.34
58940 514.61 488.88 562.21
# 59812 300.62 285.59 328.43
59820 388.38 368.96 424.30
# 58321 51.14 48.58 55.87
58322 92.79 88.15 101.37
58943 1,139.29 1,082.33 1,244.68
58950 1,088.45 1,034.03 1,189.13
# 59820 358.78 340.84 391.97
59821 393.62 373.94 430.03
# 58322 60.53 57.50 66.13
58323 20.55 19.52 22.45
58951 1,399.46 1,329.49 1,528.91
58952 1,579.08 1,500.13 1,725.15
# 59821 362.25 344.14 395.76
59830 447.44 425.07 488.83
# 58323 13.04 12.39 14.25 58953 1,956.71 1,858.87 2,137.70 59840 225.50 214.23 246.36
58340 141.24 134.18 154.31
# 58340 62.16 59.05 67.91
58954 2,123.38 2,017.21 2,319.79
58956 1,379.34 1,310.37 1,506.93
# 59840 217.54 206.66 237.66
59841 389.56 370.08 425.59
58345 286.19 271.88 312.66
58346 468.50 445.08 511.84
58957 1,506.67 1,431.34 1,646.04
58958 1,673.79 1,590.10 1,828.62
# 59841 365.26 347.00 399.05
59850 400.02 380.02 437.02
58350 103.12 97.96 112.65 58960 941.34 894.27 1,028.41 59851 411.81 391.22 449.90
# 58350 81.91 77.81 89.48
58353 1,284.18 1,219.97 1,402.97
58970 232.99 221.34 254.54
# 58970 205.16 194.90 224.14
59852 578.86 549.92 632.41
59855 426.06 404.76 465.47
# 58353 227.80 216.41 248.87
58356 2,354.56 2,236.83 2,572.35
58976 267.95 254.55 292.73
# 58976 231.28 219.72 252.68
59856 501.56 476.48 547.95
59857 599.94 569.94 655.43
# 58356 358.00 340.10 391.12
58400 462.22 439.11 504.98
59000 138.65 131.72 151.48
# 59000 83.87 79.68 91.63
59866 246.61 234.28 269.42
59870 486.03 461.73 530.99
58410 819.74 778.75 895.56 59001 191.54 181.96 209.25 59871 138.65 131.72 151.48
58520 800.35 760.33 874.38
58540 928.70 882.27 1,014.61
59012 209.93 199.43 229.34
59015 163.07 154.92 178.16
60000 165.29 157.03 180.58
# 60000 149.82 142.33 163.68
58541 877.19 833.33 958.33
58542 972.50 923.88 1,062.46
# 59015 137.00 130.15 149.67
59020 76.06 72.26 83.10
60100 122.00 115.90 133.29
# 60100 86.21 81.90 94.19
58543 988.39 938.97 1,079.82 5902026 38.70 36.77 42.29 60200 655.41 622.64 716.04
58544 1,067.02 1,013.67 1,165.72
58545 914.01 868.31 998.56
59020 TC 37.36 35.49 40.81
59025 49.87 47.38 54.49
60210 696.85 662.01 761.31
60212 998.44 948.52 1,090.80
58546 1,156.50 1,098.68 1,263.48
58548 1,799.80 1,709.81 1,966.28
5902526 31.18 29.62 34.06
59025 TC 18.69 17.76 20.42
60220 763.47 725.30 834.10
60225 918.22 872.31 1,003.16
58550 904.70 859.47 988.39
58552 996.52 946.69 1,088.69
59030 116.18 110.37 126.93
59050 51.88 49.29 56.68
60240 967.60 919.22 1,057.10
60252 1,306.59 1,241.26 1,427.45
58553 1,162.33 1,104.21 1,269.84 59051 42.87 40.73 46.84 60254 1,683.48 1,599.31 1,839.21
58554 1,331.40 1,264.83 1,454.55
58555 252.82 240.18 276.21
59070 416.93 396.08 455.49
# 59070 298.08 283.18 325.66
60260 1,091.84 1,037.25 1,192.84
60270 1,374.67 1,305.94 1,501.83
# 58555 196.27 186.46 214.43
58558 339.85 322.86 371.29
59072 488.41 463.99 533.59
59074 393.07 373.42 429.43
60271 1,055.23 1,002.47 1,152.84
60280 445.60 423.32 486.82
# 58558 276.23 262.42 301.78 # 59074 294.99 280.24 322.28 60281 590.30 560.79 644.91
58559 354.80 337.06 387.62
58560 400.79 380.75 437.86
59076 476.04 452.24 520.08
59100 843.18 801.02 921.17
60300 117.98 112.08 128.89
# 60300 53.03 50.38 57.94
58561 566.57 538.24 618.98
58562 357.98 340.08 391.09
59120 806.54 766.21 881.14
59121 809.96 769.46 884.88
60500 1,003.91 953.71 1,096.77
60502 1,259.67 1,196.69 1,376.19
# 58562 300.98 285.93 328.82
58563 2,088.04 1,983.64 2,281.19
59130 943.49 896.32 1,030.77
59135 958.14 910.23 1,046.76
60505 1,385.01 1,315.76 1,513.12
60512 243.04 230.89 265.52
# 58563 354.80 337.06 387.62 59136 892.71 848.07 975.28 60520 1,035.17 983.41 1,130.92
58565 2,216.62 2,105.79 2,421.66
# 58565 458.19 435.28 500.57
59140 404.11 383.90 441.49
59150 784.23 745.02 856.77
60521 1,192.04 1,132.44 1,302.31
60522 1,435.28 1,363.52 1,568.05
58570 941.01 893.96 1,028.05
58571 1,032.10 980.50 1,127.58
59151 765.42 727.15 836.22
59160 224.44 213.22 245.20
60540 1,092.98 1,038.33 1,194.08
60545 1,240.08 1,178.08 1,354.79
58572 1,167.19 1,108.83 1,275.15 # 59160 185.56 176.28 202.72 60600 1,435.03 1,363.28 1,567.77
58573 1,318.59 1,252.66 1,440.56
58600 373.47 354.80 408.02
59200 79.35 75.38 86.69
# 59200 46.22 43.91 50.50
60605 1,801.96 1,711.86 1,968.64
60650 1,212.09 1,151.49 1,324.21
58605 340.14 323.13 371.60
58611 79.98 75.98 87.38
59300 202.45 192.33 221.18
# 59300 150.75 143.21 164.69
61000 113.02 107.37 123.48
61001 110.95 105.40 121.21
58615 257.63 244.75 281.46
58660 687.71 653.32 751.32
59320 158.38 150.46 173.03
59325 248.64 236.21 271.64
61020 134.15 127.44 146.56
61026 132.67 126.04 144.95
58661 659.29 626.33 720.28 59350 283.91 269.71 310.17 61050 112.90 107.26 123.35
58662 723.43 687.26 790.35
58670 376.41 357.59 411.23
59400 1,815.61 1,724.83 1,983.55
59409 789.02 749.57 862.01
61055 144.30 137.09 157.65
61070 86.06 81.76 94.02
58671 376.26 357.45 411.07
58672 760.17 722.16 830.48
59410 918.70 872.77 1,003.69
59412 106.73 101.39 116.60
61105 437.63 415.75 478.11
61107 317.10 301.25 346.44
58673 826.83 785.49 903.31 59414 94.00 89.30 102.70 61108 863.48 820.31 943.36
58700 780.35 741.33 852.53
58720 733.32 696.65 801.15
59425 456.13 433.32 498.32
# 59425 347.00 329.65 379.10
61120 707.27 671.91 772.70
61140 1,222.31 1,161.19 1,335.37
58740 893.68 849.00 976.35
58750 929.01 882.56 1,014.94
59426 816.97 776.12 892.54
# 59426 613.74 583.05 670.51
61150 1,304.31 1,239.09 1,424.95
61151 945.99 898.69 1,033.49
58752 936.68 889.85 1,023.33
58760 842.59 800.46 920.53
59430 144.84 137.60 158.24
# 59430 129.37 122.90 141.34
61154 1,226.11 1,164.80 1,339.52
61156 1,218.41 1,157.49 1,331.11
58770 860.46 817.44 940.06 59510 2,055.98 1,953.18 2,246.16 61210 370.19 351.68 404.43
58800 333.14 316.48 363.95
# 58800 307.96 292.56 336.44
59514 934.36 887.64 1,020.79
59515 1,107.54 1,052.16 1,209.98
61215 476.73 452.89 520.82
61250 825.50 784.23 901.86
CODES: 58280 - 61250
# - These amounts apply when the service is performed in a facility setting.
C - The payment for the technical component is capped at the OPPS amount.
Limiting charge applies to unassigned claims by non-participating providers. All CPT codes and modifiers are bolded.
All Current Procedural Terminology (CPT) codes and descriptors are copyrighted 2008 by the American Medical Association..

61253
61304
61305
61312
61313
61314
61315
61316
61320
61321
61322
61323
61330
61332
61333
61334
61340
61343
61345
61440
61450
61458
61460
61470
61480
61490
61500
61501
61510
61512
61514
61516
61517
61518
61519
61520
61521
61522
61524
61526
61530
61531
61533
61534
61535
61536
61537
61538
61539
61540
61541
61542
61543
61544
61545
61546
61548
61550
61552
61556
61557
61558
61559
61563
61564
61566
61567
61570
61571
61575
61576
61580
61581
61582
61583
61584
61585
61586
61590
61591
61592
61595
61596
61597
61598
61600
61601
61605
61606
61607
61608
61609
61610
61611
61612
61613
61615
61616
61618
61619
61623
61624
61626
61630
61635
61680
61682
61684
61686
61690
61692
61697
61698
61700
61702
61703
61705
61708
61710
61711
61720
61735
61750
61751
61760
61770
61790
61791
61795
61796
61797
61798
61799
61800
61850
61860
61863
61864
61867
61868
61870
61875
61880
61885
61886
61888
62000
62005
62010
62100
62115
62116
62117
62120
62121
62140
62141
62142
62143
62145
62146
62147
62148
62160
62161
62162
62163
62164
62165
62180
62190
62192
62194
62200
62201
62220
62223
62225
62230
62252
6225226
62252TC
62256
62258
62263
62263
62264
62264
62267
62267
62268
62268
62269
62269
62270
62270
62272
62272
62273
62273
62280
62280
62281
62281
62282
62282
62284
62284
62287
62290
62290
62291
62291
62292
62294
62310
62310
62311
62311
62318
62318
62319
62319
62350
62351
62355
62360
62361
62362
62365
62367






California - MEDICARE CARRIER 01192 FSY2009 LOCALITY 18 FEE SCHEDULE PAGE: 27
PROCEDURE PAR NONPAR LIMITING
CODE/MOD FEE FEE CHARGE
PROCEDURE PAR NONPAR LIMITING
CODE/MOD FEE FEE CHARGE
PROCEDURE PAR NONPAR LIMITING
CODE/MOD FEE FEE CHARGE
61253 903.31 858.14 986.86
61304 1,605.29 1,525.03 1,753.78
61586 2,133.11 2,026.45 2,330.42
61590 3,088.51 2,934.08 3,374.19
62121 1,627.77 1,546.38 1,778.34
62140 1,024.00 972.80 1,118.72
61305 1,933.15 1,836.49 2,111.96 61591 3,112.36 2,956.74 3,400.25 62141 1,123.94 1,067.74 1,227.90
61312 2,001.76 1,901.67 2,186.92
61313 1,919.10 1,823.15 2,096.62
61592 3,122.46 2,966.34 3,411.29
61595 2,350.01 2,232.51 2,567.39
62142 859.77 816.78 939.30
62143 1,004.75 954.51 1,097.69
61314 1,776.58 1,687.75 1,940.91
61315 2,021.10 1,920.05 2,208.06
61596 2,567.26 2,438.90 2,804.74
61597 2,818.97 2,678.02 3,079.72
62145 1,371.88 1,303.29 1,498.78
62146 1,177.24 1,118.38 1,286.14
61316 87.08 82.73 95.14 61598 2,500.33 2,375.31 2,731.61 62147 1,396.83 1,326.99 1,526.04
61320 1,868.94 1,775.49 2,041.81
61321 2,045.16 1,942.90 2,234.34
61600 2,118.75 2,012.81 2,314.73
61601 2,323.03 2,206.88 2,537.91
62148 124.35 118.13 135.85
62160 191.07 181.52 208.75
61322 2,268.23 2,154.82 2,478.04
61323 2,305.56 2,190.28 2,518.82
61605 2,211.31 2,100.74 2,415.85
61606 2,964.48 2,816.26 3,238.70
62161 1,478.18 1,404.27 1,614.91
62162 1,835.43 1,743.66 2,005.21
61330 1,574.28 1,495.57 1,719.91
61332 1,827.32 1,735.95 1,996.34
61607 2,736.93 2,600.08 2,990.09
61608 3,195.16 3,035.40 3,490.71
62163 1,194.60 1,134.87 1,305.10
62164 1,951.70 1,854.12 2,132.24
61333 1,844.20 1,751.99 2,014.79 61609 608.65 578.22 664.95 62165 1,512.59 1,436.96 1,652.50
61334 1,193.33 1,133.66 1,303.71
61340 1,394.42 1,324.70 1,523.41
61610 1,870.21 1,776.70 2,043.21
61611 472.63 449.00 516.35
62180 1,546.64 1,469.31 1,689.71
62190 885.17 840.91 967.05
61343 2,148.48 2,041.06 2,347.22
61345 1,990.36 1,890.84 2,174.47
61612 1,653.59 1,570.91 1,806.55
61613 3,102.24 2,947.13 3,389.20
62192 940.71 893.67 1,027.72
62194 382.20 363.09 417.55
61440 1,948.11 1,850.70 2,128.31 61615 2,454.85 2,332.11 2,681.93 62200 1,339.12 1,272.16 1,462.98
61450 1,841.75 1,749.66 2,012.11
61458 1,968.36 1,869.94 2,150.43
61616 3,222.24 3,061.13 3,520.30
61618 1,271.58 1,208.00 1,389.20
62201 1,153.96 1,096.26 1,260.70
62220 987.72 938.33 1,079.08
61460 1,988.68 1,889.25 2,172.64
61470 1,848.50 1,756.08 2,019.49
61619 1,462.26 1,389.15 1,597.52
61623 580.75 551.71 634.47
62223 1,017.64 966.76 1,111.77
62225 489.29 464.83 534.55
61480 1,786.65 1,697.32 1,951.92
61490 1,863.06 1,769.91 2,035.40
61624 1,153.77 1,096.08 1,260.49
61626 938.88 891.94 1,025.73
62230 817.97 777.07 893.63
62252 106.77 101.43 116.64
61500 1,318.65 1,252.72 1,440.63 61630 1,320.62 1,254.59 1,442.78 6225226 46.99 44.64 51.34
61501 1,131.36 1,074.79 1,236.01
61510 2,125.72 2,019.43 2,322.34
61635 1,445.34 1,373.07 1,579.03
61680 2,217.08 2,106.23 2,422.16
62252TC 59.78 56.79 65.31
62256 572.26 543.65 625.20
61512 2,503.04 2,377.89 2,734.57
61514 1,860.57 1,767.54 2,032.67
61682 4,148.48 3,941.06 4,532.22
61684 2,766.42 2,628.10 3,022.32
62258 1,097.93 1,043.03 1,199.48
62263 682.88 648.74 746.05
61516 1,815.19 1,724.43 1,983.09 61686 4,444.91 4,222.66 4,856.06 # 62263 383.33 364.16 418.78
61517 87.15 82.79 95.21
61518 2,694.28 2,559.57 2,943.51
61690 2,107.53 2,002.15 2,302.47
61692 3,589.70 3,410.22 3,921.75
62264 414.57 393.84 452.92
# 62264 230.77 219.23 252.11
61519 2,897.25 2,752.39 3,165.25
61520 3,694.12 3,509.41 4,035.82
61697 4,049.59 3,847.11 4,424.18
61698 4,349.18 4,131.72 4,751.48
62267 268.64 255.21 293.49
# 62267 170.11 161.60 185.84
61521 3,110.83 2,955.29 3,398.58
61522 2,139.42 2,032.45 2,337.32
61700 3,400.17 3,230.16 3,714.68
61702 3,789.04 3,599.59 4,139.53
62268 494.91 470.16 540.68
# 62268 275.77 261.98 301.28
61524 2,019.06 1,918.11 2,205.83 61703 1,310.69 1,245.16 1,431.93 62269 537.70 510.82 587.44
61526 3,340.31 3,173.29 3,649.28
61530 2,839.67 2,697.69 3,102.34
61705 2,498.40 2,373.48 2,729.50
61708 2,136.59 2,029.76 2,334.22
# 62269 279.24 265.28 305.07
62270 165.54 157.26 180.85
61531 1,177.53 1,118.65 1,286.45
61533 1,480.61 1,406.58 1,617.57
61710 1,958.65 1,860.72 2,139.83
61711 2,549.71 2,422.22 2,785.55
# 62270 79.82 75.83 87.20
62272 196.85 187.01 215.06
61534 1,596.00 1,516.20 1,743.63 61720 1,135.89 1,079.10 1,240.97 # 62272 85.07 80.82 92.94
61535 960.15 912.14 1,048.96
61536 2,535.96 2,409.16 2,770.53
61735 1,390.58 1,321.05 1,519.21
61750 1,368.94 1,300.49 1,495.56
62273 171.09 162.54 186.92
# 62273 112.33 106.71 122.72
61537 2,324.17 2,207.96 2,539.15
61538 2,489.38 2,364.91 2,719.65
61751 1,338.39 1,271.47 1,462.19
61760 1,502.47 1,427.35 1,641.45
62280 325.70 309.42 355.83
# 62280 156.04 148.24 170.48
61539 2,294.84 2,180.10 2,507.12
61540 2,157.80 2,049.91 2,357.40
61770 1,476.63 1,402.80 1,613.22
61790 832.09 790.49 909.06
62281 300.22 285.21 327.99
# 62281 149.56 142.08 163.39
61541 2,066.99 1,963.64 2,258.19 61791 1,074.58 1,020.85 1,173.98 62282 314.20 298.49 343.26
61542 2,244.82 2,132.58 2,452.47
61543 2,094.58 1,989.85 2,288.33
61795 247.12 234.76 269.97
61796 784.31 745.09 856.85
# 62282 138.80 131.86 151.64
62284 241.41 229.34 263.74
61544 1,717.50 1,631.63 1,876.37
61545 3,084.00 2,929.80 3,369.27
61797 210.74 200.20 230.23
61798 784.31 745.09 856.85
# 62284 94.28 89.57 103.01
62287 557.87 529.98 609.48
61546 2,236.50 2,124.68 2,443.38 61799 291.33 276.76 318.27 62290 346.84 329.50 378.93
61548 1,513.92 1,438.22 1,653.95
61550 992.06 942.46 1,083.83
61800 150.05 142.55 163.93
61850 956.16 908.35 1,044.60
# 62290 174.53 165.80 190.67
62291 324.01 307.81 353.98
61552 1,303.40 1,238.23 1,423.96
61556 1,593.94 1,514.24 1,741.38
61860 1,516.32 1,440.50 1,656.58
61863 1,477.68 1,403.80 1,614.37
# 62291 168.49 160.07 184.08
62292 493.74 469.05 539.41
61557 1,650.53 1,568.00 1,803.20
61558 1,685.29 1,601.03 1,841.18
61864 409.98 389.48 447.90
61867 2,162.03 2,053.93 2,362.02
62294 806.57 766.24 881.18
# 62310 102.14 97.03 111.58
61559 2,356.44 2,238.62 2,574.41 61868 602.01 571.91 657.70 62310 229.39 217.92 250.61
61563 1,887.21 1,792.85 2,061.78
61564 2,368.00 2,249.60 2,587.04
61870 1,157.15 1,099.29 1,264.18
61875 1,123.93 1,067.73 1,227.89
62311 203.58 193.40 222.41
# 62311 85.17 80.91 93.05
61566 2,183.47 2,074.30 2,385.45
61567 2,453.79 2,331.10 2,680.77
61880 537.58 510.70 587.31
61885 626.34 595.02 684.27
62318 245.31 233.04 268.00
# 62318 101.72 96.63 111.12
61570 1,786.56 1,697.23 1,951.81 61886 786.94 747.59 859.73 62319 221.85 210.76 242.37
61571 1,942.98 1,845.83 2,122.70
61575 2,297.57 2,182.69 2,510.09
61888 391.53 371.95 427.74
62000 848.66 806.23 927.16
# 62319 95.49 90.72 104.33
62350 391.37 371.80 427.57
61576 3,698.20 3,513.29 4,040.28
61580 2,444.29 2,322.08 2,670.39
62005 1,208.23 1,147.82 1,319.99
62010 1,476.29 1,402.48 1,612.85
62351 832.53 790.90 909.54
62355 295.14 280.38 322.44
61581 2,741.59 2,604.51 2,995.19
61582 2,844.65 2,702.42 3,107.78
62100 1,567.20 1,488.84 1,712.17
62115 1,379.14 1,310.18 1,506.71
62360 283.22 269.06 309.42
62361 392.51 372.88 428.81
61583 2,853.93 2,711.23 3,117.91 62116 1,731.92 1,645.32 1,892.12 62362 412.91 392.26 451.10
61584 2,778.56 2,639.63 3,035.57
61585 2,927.75 2,781.36 3,198.56
62117 1,861.30 1,768.24 2,033.48
62120 1,789.60 1,700.12 1,955.14
62365 327.54 311.16 357.83
62367 40.10 38.10 43.82
CODES: 61253 - 62367
# - These amounts apply when the service is performed in a facility setting.
C - The payment for the technical component is capped at the OPPS amount.
Limiting charge applies to unassigned claims by non-participating providers. All CPT codes and modifiers are bolded.
All Current Procedural Terminology (CPT) codes and descriptors are copyrighted 2008 by the American Medical Association.

62367
62368
62368
63001
63003
63005
63011
63012
63015
63016
63017
63020
63030
63035
63040
63042
63043
63044
63045
63046
63047
63048
63050
63051
63055
63056
63057
63064
63066
63075
63076
63077
63078
63081
63082
63085
63086
63087
63088
63090
63091
63101
63102
63103
63170
63172
63173
63180
63182
63185
63190
63191
63194
63195
63196
63197
63198
63199
63200
63250
63251
63252
63265
63266
63267
63268
63270
63271
63272
63273
63275
63276
63277
63278
63280
63281
63282
63283
63285
63286
63287
63290
63295
63300
63301
63302
63303
63304
63305
63306
63307
63308
63600
63610
63610
63615
63620
63621
63650
63655
63660
63685
63688
63700
63702
63704
63706
63707
63709
63710
63740
63741
63744
63746
64400
64400
64402
64402
64405
64405
64408
64408
64410
64410
64412
64412
64413
64413
64415
64415
64416
64417
64417
64418
64418
64420
64420
64421
64421
64425
64425
64430
64430
64435
64435
64445
64445
64446
64447
64448
64449
64450
64450
64455
64455
64470
64470
64472
64472
64475
64475
64476
64476
64479
64479
64480
64480
64483
64483
64484
64484
64505
64505
64508
64508
64510
64510
64517
64517
64520
64520
64530
64530
64550
64550
64553
64553
64555
64555
64560
64560
64561
64561
64565
64565
64573
64575
64577
64580
64581
64585
64585
64590
64590
64595
64595
64600
64600
64605
64605
64610
64610
64612
64612
64613
64613
64614
64614
64620
64620
64622
64622
64623
64623
64626
64626
64627
64627
64630
64630
64632






California - MEDICARE CARRIER 01192 FSY2009 LOCALITY 18 FEE SCHEDULE PAGE: 28
PROCEDURE PAR NONPAR CHARGE
CODE/MOD FEE FEE LIMIT
PROCEDURE PAR NONPAR CHARGE
CODE/MOD FEE FEE LIMIT
PROCEDURE PAR NONPAR CHARGE
CODE/MOD FEE FEE LIMIT
# 62367 24.19 22.98 26.43
62368 56.85 54.01 62.11
63283 1,832.42 1,740.80 2,001.92
63285 2,536.55 2,409.72 2,771.18
# 64455 41.37 39.30 45.20
64470 279.42 265.45 305.27
# 62368 37.85 35.96 41.35 63286 2,530.12 2,403.61 2,764.15 # 64470 104.90 99.66 114.61
63001 1,205.02 1,144.77 1,316.49
63003 1,212.28 1,151.67 1,324.42
63287 2,666.58 2,533.25 2,913.24
63290 2,696.44 2,561.62 2,945.86
64472 117.47 111.60 128.34
# 64472 66.22 62.91 72.35
63005 1,154.61 1,096.88 1,261.41
63011 1,088.11 1,033.70 1,188.76
63295 317.99 302.09 347.40
63300 1,804.62 1,714.39 1,971.55
64475 252.00 239.40 275.31
# 64475 82.79 78.65 90.45
63012 1,173.43 1,114.76 1,281.97 63301 2,013.41 1,912.74 2,199.65 64476 99.35 94.38 108.54
63015 1,449.81 1,377.32 1,583.92
63016 1,486.85 1,412.51 1,624.39
63302 2,002.59 1,902.46 2,187.83
63303 2,086.62 1,982.29 2,279.63
# 64476 49.43 46.96 54.00
64479 294.17 279.46 321.38
63017 1,217.58 1,156.70 1,330.21
63020 1,153.17 1,095.51 1,259.84
63304 2,227.56 2,116.18 2,433.61
63305 2,261.21 2,148.15 2,470.37
# 64479 124.08 117.88 135.56
64480 144.66 137.43 158.04
63030 960.44 912.42 1,049.28
63035 201.26 191.20 219.88
63306 2,390.80 2,271.26 2,611.95
63307 2,203.12 2,092.96 2,406.90
# 64480 80.16 76.15 87.57
64483 287.92 273.52 314.55
63040 1,395.72 1,325.93 1,524.82 63308 332.23 315.62 362.96 # 64483 109.43 103.96 119.55
63042 1,309.13 1,243.67 1,430.22
63043 317.00 301.15 346.32
63600 818.75 777.81 894.48
63610 1,442.73 1,370.59 1,576.18
64484 143.27 136.11 156.53
# 64484 68.16 64.75 74.46
63044 342.81 325.67 374.52
63045 1,249.99 1,187.49 1,365.61
# 63610 433.19 411.53 473.26
63615 1,122.83 1,066.69 1,226.69
64505 104.33 99.11 113.98
# 64505 85.77 81.48 93.70
63046 1,194.45 1,134.73 1,304.94 63620 784.31 745.09 856.85 64508 151.00 143.45 164.97
63047 1,093.07 1,038.42 1,194.18
63048 216.11 205.30 236.10
63621 242.29 230.18 264.71
63650 408.85 388.41 446.67
# 64508 71.03 67.48 77.60
64510 149.45 141.98 163.28
63050 1,499.02 1,424.07 1,637.68
63051 1,688.75 1,604.31 1,844.96
63655 834.79 793.05 912.01
63660 436.07 414.27 476.41
# 64510 68.16 64.75 74.46
64517 174.59 165.86 190.74
63055 1,604.86 1,524.62 1,753.31
63056 1,481.42 1,407.35 1,618.45
63685 397.98 378.08 434.79
63688 357.67 339.79 390.76
# 64517 119.37 113.40 130.41
64520 197.48 187.61 215.75
63057 331.46 314.89 362.12 63700 1,207.27 1,146.91 1,318.95 # 64520 77.31 73.44 84.46
63064 1,751.75 1,664.16 1,913.78
63066 204.26 194.05 223.16
63702 1,359.37 1,291.40 1,485.11
63704 1,508.67 1,433.24 1,648.23
64530 202.72 192.58 221.47
# 64530 91.38 86.81 99.83
63075 1,373.80 1,305.11 1,500.88
63076 255.95 243.15 279.62
63706 1,762.60 1,674.47 1,925.64
63707 893.94 849.24 976.63
64550 16.33 15.51 17.84
# 64550 9.26 8.80 10.12
63077 1,497.38 1,422.51 1,635.89 63709 1,083.93 1,029.73 1,184.19 64553 210.22 199.71 229.67
63078 203.26 193.10 222.07
63081 1,757.91 1,670.01 1,920.51
63710 1,084.41 1,030.19 1,184.72
63740 923.49 877.32 1,008.92
# 64553 161.62 153.54 176.57
64555 224.47 213.25 245.24
63082 276.34 262.52 301.90
63085 1,869.32 1,775.85 2,042.23
63741 593.56 563.88 648.46
63744 627.65 596.27 685.71
# 64555 159.09 151.14 173.81
64560 221.65 210.57 242.16
63086 195.64 185.86 213.74
63087 2,387.03 2,267.68 2,607.83
63746 551.62 524.04 602.65
64400 111.74 106.15 122.07
# 64560 163.78 155.59 178.93
64561 1,254.00 1,191.30 1,370.00
63088 268.15 254.74 292.95 # 64400 63.59 60.41 69.47 # 64561 441.06 419.01 481.86
63090 1,953.11 1,855.45 2,133.77
63091 183.79 174.60 200.79
64402 113.60 107.92 124.11
# 64402 72.52 68.89 79.22
64565 177.52 168.64 193.94
# 64565 121.41 115.34 132.64
63101 2,245.43 2,133.16 2,453.13
63102 2,234.82 2,123.08 2,441.54
64405 106.22 100.91 116.05
# 64405 73.97 70.27 80.81
64573 586.99 557.64 641.29
64575 286.91 272.56 313.44
63103 293.76 279.07 320.93 64408 123.44 117.27 134.86 64577 360.77 342.73 394.14
63170 1,507.91 1,432.51 1,647.39
63172 1,359.20 1,291.24 1,484.93
# 64408 90.74 86.20 99.13
64410 145.10 137.85 158.53
64580 299.75 284.76 327.47
64581 852.87 810.23 931.76
63173 1,675.77 1,591.98 1,830.78
63180 1,361.45 1,293.38 1,487.39
# 64410 79.27 75.31 86.61
64412 146.03 138.73 159.54
64585 362.24 344.13 395.75
# 64585 166.96 158.61 182.40
63182 1,451.08 1,378.53 1,585.31
63185 1,110.30 1,054.79 1,213.01
# 64412 71.36 67.79 77.96
64413 118.50 112.58 129.47
64590 336.72 319.88 367.86
# 64590 186.06 176.76 203.27
63190 1,276.64 1,212.81 1,394.73 # 64413 76.97 73.12 84.09 64595 353.09 335.44 385.76
63191 1,208.01 1,147.61 1,319.75
63194 1,446.78 1,374.44 1,580.61
64415 135.49 128.72 148.03
# 64415 73.64 69.96 80.45
# 64595 148.09 140.69 161.79
64600 424.30 403.09 463.55
63195 1,468.04 1,394.64 1,603.84
63196 1,728.71 1,642.27 1,888.61
64416 92.85 88.21 101.44
64417 137.22 130.36 149.91
# 64600 215.32 204.55 235.23
64605 591.78 562.19 646.52
63197 1,648.13 1,565.72 1,800.58 # 64417 73.16 69.50 79.93 # 64605 341.72 324.63 373.32
63198 1,803.70 1,713.52 1,970.55
63199 1,918.56 1,822.63 2,096.02
64418 140.84 133.80 153.87
# 64418 73.68 70.00 80.50
64610 717.07 681.22 783.40
# 64610 485.12 460.86 529.99
63200 1,474.83 1,401.09 1,611.25
63250 2,843.74 2,701.55 3,106.78
64420 170.33 161.81 186.08
# 64420 66.51 63.18 72.66
64612 158.38 150.46 173.03
# 64612 137.62 130.74 150.35
63251 2,957.05 2,809.20 3,230.58
63252 2,959.37 2,811.40 3,233.11
64421 251.83 239.24 275.13
# 64421 90.57 86.04 98.95
64613 155.73 147.94 170.13
# 64613 129.22 122.76 141.17
63265 1,632.45 1,550.83 1,783.45 64425 131.33 124.76 143.47 64614 174.75 166.01 190.91
63266 1,676.76 1,592.92 1,831.86
63267 1,354.29 1,286.58 1,479.57
# 64425 93.77 89.08 102.44
64430 165.08 156.83 180.35
# 64614 143.82 136.63 157.12
64620 281.95 267.85 308.03
63268 1,356.41 1,288.59 1,481.88
63270 2,005.08 1,904.83 2,190.55
# 64430 90.41 85.89 98.77
64435 152.30 144.69 166.39
# 64620 167.08 158.73 182.54
64622 340.40 323.38 371.89
63271 2,017.65 1,916.77 2,204.29 # 64435 86.03 81.73 93.99 # 64622 177.37 168.50 193.78
63272 1,859.52 1,766.54 2,031.52
63273 1,752.42 1,664.80 1,914.52
64445 141.09 134.04 154.15
# 64445 81.00 76.95 88.49
64623 127.27 120.91 139.05
# 64623 49.07 46.62 53.61
63275 1,751.14 1,663.58 1,913.12
63276 1,745.19 1,657.93 1,906.62
64446 92.75 88.11 101.33
64447 69.53 66.05 75.96
64626 393.99 374.29 430.43
# 64626 235.38 223.61 257.15
63277 1,533.44 1,456.77 1,675.29
63278 1,499.96 1,424.96 1,638.70
64448 81.88 77.79 89.46
64449 91.75 87.16 100.23
64627 175.03 166.28 191.22
# 64627 57.51 54.63 62.82
63280 2,072.45 1,968.83 2,264.15 64450 106.68 101.35 116.55 # 64630 196.64 186.81 214.83
63281 2,048.56 1,946.13 2,238.05
63282 1,934.45 1,837.73 2,113.39
# 64450 73.10 69.45 79.87
64455 53.74 51.05 58.71
64630 240.38 228.36 262.61
64632 88.48 84.06 96.67
CODES: 62367 - 64632
# - These amounts apply when the service is performed in a facility setting.
C - The payment for the technical component is capped at the OPPS amount.
Limiting charge applies to unassigned claims by non-participating providers. All CPT codes and modifiers are bolded.
All Current Procedural Terminology (CPT) codes and descriptors are copyrighted 2008 by the American Medical Association..

64632
64640
64640
64650
64650
64653
64653
64680
64680
64681
64681
64702
64704
64708
64712
64713
64714
64716
64718
64719
64721
64721
64722
64726
64727
64732
64734
64736
64738
64740
64742
64744
64746
64752
64755
64760
64761
64763
64766
64771
64772
64774
64776
64778
64782
64783
64784
64786
64787
64788
64790
64792
64795
64802
64804
64809
64818
64820
64821
64822
64823
64831
64832
64834
64835
64836
64837
64840
64856
64857
64858
64859
64861
64862
64864
64865
64866
64868
64870
64872
64874
64876
64885
64886
64890
64891
64892
64893
64895
64896
64897
64898
64901
64902
64905
64907
64910
64911
65091
65093
65101
65103
65105
65110
65112
65114
65125
65125
65130
65135
65140
65150
65155
65175
65205
65205
65210
65210
65220
65220
65222
65222
65235
65260
65265
65270
65270
65272
65272
65273
65275
65275
65280
65285
65286
65286
65290
65400
65400
65410
65410
65420
65420
65426
65426
65430
65430
65435
65435
65436
65436
65450
65450
65600
65600
65710
65730
65750
65755
65756
65770
65772
65772
65775
65780
65781
65782
65800
65800
65805
65805
65810
65815
65815
65820
65850
65855
65855
65860
65860
65865
65870
65875
65880
65900
65920
65930
66020
66020
66030
66030
66130
66130
66150
66155
66160
66165
66170
66172
66180
66185
66220
66225
66250
66250
66500
66505
66600
66605
66625
66630
66635
66680
66682
66700
66700
66710
66710
66711
66720
66720
66740
66740
66761
66761
66762
66762
66770
66770
66820
66821






California - MEDICARE CARRIER 01192 FSY2009 LOCALITY 18 FEE SCHEDULE PAGE: 29
PROCEDURE PAR NONPAR LIMITING
CODE/MOD FEE FEE CHARGE
PROCEDURE
CODE/MOD
PAR
FEE
NONPAR
FEE
LIMITING
CHARGE
PROCEDURE
CODE/MOD
PAR
FEE
NONPAR LIMITING
FEE CHARGE
# 64632 74.34 70.62 81.21
64640 237.82 225.93 259.82
# 64640 179.94 170.94 196.58
64650 69.99 66.49 76.46
# 64650 39.95 37.95 43.64
64653 80.87 76.83 88.35
# 64653 49.94 47.44 54.56
64680 323.48 307.31 353.41
# 64680 163.10 154.95 178.19
64681 415.13 394.37 453.53
# 64681 217.64 206.76 237.77
64702 463.65 440.47 506.54
64704 340.11 323.10 371.57
64708 482.28 458.17 526.90
64712 548.51 521.08 599.24
64713 765.90 727.61 836.75
64714 648.71 616.27 708.71
64716 527.22 500.86 575.99
64718 570.77 542.23 623.56
64719 395.91 376.11 432.53
64721 420.26 399.25 459.14
# 64721 418.49 397.57 457.21
64722 335.03 318.28 366.02
64726 294.78 280.04 322.05
64727 189.51 180.03 207.03
64732 387.06 367.71 422.87
64734 416.43 395.61 454.95
64736 393.69 374.01 430.11
64738 463.40 440.23 506.26
64740 463.62 440.44 506.51
64742 470.77 447.23 514.31
64744 415.05 394.30 453.45
64746 445.26 423.00 486.45
64752 501.92 476.82 548.34
64755 881.82 837.73 963.39
64760 471.71 448.12 515.34
64761 447.80 425.41 489.22
64763 549.02 521.57 599.81
64766 627.06 595.71 685.07
64771 593.92 564.22 648.85
64772 570.66 542.13 623.45
64774 411.31 390.74 449.35
64776 394.97 375.22 431.50
64778 187.98 178.58 205.37
64782 463.42 440.25 506.29
64783 224.77 213.53 245.56
64784 721.49 685.42 788.23
64786 1,079.87 1,025.88 1,179.76
64787 257.86 244.97 281.72
64788 387.78 368.39 423.65
64790 825.18 783.92 901.51
64792 1,068.95 1,015.50 1,167.83
64795 194.36 184.64 212.34
64802 596.83 566.99 652.04
64804 907.97 862.57 991.96
64809 854.47 811.75 933.51
64818 663.81 630.62 725.21
64820 758.15 720.24 828.28
64821 687.18 652.82 750.74
64822 677.87 643.98 740.58
64823 767.36 728.99 838.34
64831 681.88 647.79 744.96
64832 350.33 332.81 382.73
64834 748.53 711.10 817.77
64835 811.60 771.02 886.67
64836 811.19 770.63 886.22
64837 389.15 369.69 425.14
64840 918.35 872.43 1,003.29
64856 1,018.12 967.21 1,112.29
64857 1,063.91 1,010.71 1,162.32
64858 1,229.35 1,167.88 1,343.06
64859 263.82 250.63 288.22
64861 1,380.64 1,311.61 1,508.35
64862 1,347.54 1,280.16 1,472.18
64864 880.00 836.00 961.40
64865 1,176.43 1,117.61 1,285.25
64866 1,221.93 1,160.83 1,334.95
64868
64870
64872
64874
64876
64885
64886
64890
64891
64892
64893
64895
64896
64897
64898
64901
64902
64905
64907
64910
64911
65091
65093
65101
65103
65105
65110
65112
65114
65125
# 65125
65130
65135
65140
65150
65155
65175
65205
# 65205
65210
# 65210
65220
# 65220
65222
# 65222
65235
65260
65265
65270
# 65270
65272
# 65272
65273
65275
# 65275
65280
65285
65286
# 65286
65290
65400
# 65400
65410
# 65410
65420
# 65420
65426
# 65426
65430
# 65430
65435
# 65435
65436
# 65436
65450
# 65450
65600
1,067.67
1,024.01
123.77
181.50
197.15
1,144.80
1,358.56
1,096.58
1,127.66
1,067.12
1,121.11
1,310.43
1,449.80
1,271.20
1,387.63
617.09
708.38
1,020.12
1,338.77
826.56
992.28
597.74
597.88
689.81
719.06
792.12
1,145.43
1,348.53
1,399.12
443.01
271.59
681.06
693.41
754.89
549.80
795.52
614.96
53.59
41.67
65.83
50.37
55.06
40.92
72.31
55.08
647.88
886.64
996.52
259.38
131.25
471.87
320.33
351.19
521.27
416.56
615.76
956.20
667.07
453.23
453.29
626.71
550.28
137.19
97.87
493.11
349.52
617.81
441.52
108.91
97.87
75.91
65.75
357.82
342.36
300.07
296.10
363.63
1,014.29
972.81
117.58
172.43
187.29
1,087.56
1,290.63
1,041.75
1,071.28
1,013.76
1,065.05
1,244.91
1,377.31
1,207.64
1,318.25
586.24
672.96
969.11
1,271.83
785.23
942.67
567.85
567.99
655.32
683.11
752.51
1,088.16
1,281.10
1,329.16
420.86
258.01
647.01
658.74
717.15
522.31
755.74
584.21
50.91
39.59
62.54
47.85
52.31
38.87
68.69
52.33
615.49
842.31
946.69
246.41
124.69
448.28
304.31
333.63
495.21
395.73
584.97
908.39
633.72
430.57
430.63
595.37
522.77
130.33
92.98
468.45
332.04
586.92
419.44
103.46
92.98
72.11
62.46
339.93
325.24
285.07
281.30
345.45
1,166.43
1,118.73
135.22
198.29
215.38
1,250.69
1,484.22
1,198.01
1,231.97
1,165.82
1,224.81
1,431.65
1,583.91
1,388.79
1,515.99
674.18
773.90
1,114.48
1,462.60
903.01
1,084.07
653.03
653.19
753.62
785.58
865.39
1,251.38
1,473.27
1,528.53
483.99
296.71
744.06
757.55
824.72
600.66
869.10
671.84
58.55
45.53
71.92
55.03
60.16
44.70
78.99
60.18
707.81
968.66
1,088.69
283.37
143.39
515.52
349.96
383.67
569.49
455.09
672.72
1,044.65
728.78
495.16
495.22
684.68
601.19
149.88
106.93
538.72
381.85
674.96
482.36
118.98
106.93
82.93
71.83
390.92
374.03
327.83
323.50
397.27
# 65600
65710
65730
65750
65755
65756
65770
65772
# 65772
65775
65780
65781
65782
65800
# 65800
65805
# 65805
65810
65815
# 65815
65820
65850
65855
# 65855
65860
# 65860
65865
65870
65875
65880
65900
65920
65930
66020
# 66020
66030
# 66030
66130
# 66130
66150
66155
66160
66165
66170
66172
66180
66185
66220
66225
66250
# 66250
66500
66505
66600
66605
66625
66630
66635
66680
66682
66700
# 66700
66710
# 66710
66711
66720
# 66720
66740
# 66740
66761
# 66761
66762
# 66762
66770
# 66770
66820
66821
311.49
1,021.21
1,133.60
1,146.61
1,139.98
1,092.71
1,307.58
418.52
372.58
509.54
823.64
1,236.60
1,068.39
142.36
123.36
156.50
123.36
432.35
604.20
437.64
699.07
785.24
318.94
277.41
294.84
239.17
443.74
546.55
580.85
611.21
894.81
725.29
595.35
178.52
122.41
158.99
102.88
664.35
533.57
801.58
798.87
905.71
783.21
1,096.82
1,378.60
1,079.79
687.38
672.61
859.40
709.45
510.19
331.14
362.33
758.89
977.92
399.01
522.98
528.12
474.07
579.64
418.73
364.83
410.93
363.66
585.86
434.33
388.38
407.84
365.42
421.04
379.95
440.15
391.11
487.87
443.25
373.97
302.80
295.92 340.31
970.15 1,115.67
1,076.92 1,238.46
1,089.28 1,252.67
1,082.98 1,245.43
1,038.07 1,193.78
1,242.20 1,428.53
397.59 457.23
353.95 407.04
484.06 556.67
782.46 899.83
1,174.77 1,350.99
1,014.97 1,167.22
135.24 155.53
117.19 134.77
148.68 170.98
117.19 134.77
410.73 472.34
573.99 660.09
415.76 478.12
664.12 763.74
745.98 857.88
302.99 348.44
263.54 303.07
280.10 322.12
227.21 261.29
421.55 484.78
519.22 597.10
551.81 634.58
580.65 667.75
850.07 977.58
689.03 792.38
565.58 650.42
169.59 195.03
116.29 133.73
151.04 173.70
97.74 112.40
631.13 725.80
506.89 582.92
761.50 875.73
758.93 872.77
860.42 989.48
744.05 855.66
1,041.98 1,198.28
1,309.67 1,506.12
1,025.80 1,179.67
653.01 750.96
638.98 734.83
816.43 938.89
673.98 775.08
484.68 557.38
314.58 361.77
344.21 395.84
720.95 829.09
929.02 1,068.37
379.06 435.92
496.83 571.35
501.71 576.97
450.37 517.93
550.66 633.26
397.79 457.46
346.59 398.58
390.38 448.94
345.48 397.30
556.57 640.06
412.61 474.50
368.96 424.30
387.45 445.57
347.15 399.22
399.99 459.99
360.95 415.09
418.14 480.86
371.55 427.28
463.48 533.00
421.09 484.25
355.27 408.56
287.66 330.81
CODES: 64632 - 66821
# - These amounts apply when the service is performed in a facility setting.
C - The payment for the technical component is capped at the OPPS amount.
Limiting charge applies to unassigned claims by non-participating providers. All CPT codes and modifiers are bolded.
All Current Procedural Terminology (CPT) codes and descriptors are copyrighted 2008 by the American Medical Association.

66821
66825
66830
66840
66850
66852
66920
66930
66940
66982
66983
66984
66985
66986
66990
67005
67010
67015
67025
67025
67027
67028
67028
67030
67031
67031
67036
67039
67040
67041
67042
67043
67101
67101
67105
67105
67107
67108
67110
67110
67112
67113
67115
67120
67120
67121
67141
67141
67145
67145
67208
67208
67210
67210
67218
67220
67220
67221
67221
67225
67225
67227
67227
67228
67228
67229
67250
67255
67311
67312
67314
67316
67318
67320
67331
67332
67334
67335
67340
67343
67345
67345
67346
67400
67405
67412
67413
67414
67415
67420
67430
67440
67445
67450
67500
67500
67505
67505
67515
67515
67550
67560
67570
67700
67700
67710
67710
67715
67715
67800
67800
67801
67801
67805
67805
67808
67810
67810
67820
67820
67825
67825
67830
67830
67835
67840
67840
67850
67850
67875
67875
67880
67880
67882
67882
67900
67900
67901
67901
67902
67903
67903
67904
67904
67906
67908
67908
67909
67909
67911
67912
67912
67914
67914
67915
67915
67916
67916
67917
67917
67921
67921
67922
67922
67923
67923
67924
67924
67930
67930
67935
67935
67938
67938
67950
67950
67961
67961
67966
67966
67971
67973
67974
67975
68020
68020
68040
68040
68100
68100
68110
68110
68115
68115
68130
68130
68135
68135
68200
68200
68320
68320
68325
68326
68328
68330
68330
68335
68340
68340
68360
68360
68362
68371
68400
68400
68420
68420
68440
68440
68500
68505
68510
68510
68520
68525
68530
68530
68540
68550
68700






California - MEDICARE CARRIER 01192 FSY2009 LOCALITY 18 FEE SCHEDULE PAGE: 30
PROCEDURE PAR NONPAR CHARGE
CODE/MOD FEE FEE LIMIT
PROCEDURE PAR NONPAR CHARGE
CODE/MOD FEE FEE LIMIT
PROCEDURE PAR NONPAR CHARGE
CODE/MOD FEE FEE LIMIT
# 66821 284.24 270.03 310.53
66825 709.01 673.56 774.59
67335 141.88 134.79 155.01
67340 335.02 318.27 366.01
67915 336.35 319.53 367.46
# 67915 239.59 227.61 261.75
66830 656.27 623.46 716.98 67343 602.09 571.99 657.79 67916 513.71 488.02 561.22
66840 640.06 608.06 699.27
66850 730.11 693.60 797.64
67345 219.76 208.77 240.09
# 67345 198.11 188.20 216.43
# 67916 405.02 384.77 442.49
67917 559.91 531.91 611.70
66852 780.35 741.33 852.53
66920 696.62 661.79 761.06
67346 189.86 180.37 207.43
67400 874.79 831.05 955.71
# 67917 446.81 424.47 488.14
67921 357.34 339.47 390.39
66930 790.95 751.40 864.11 67405 746.98 709.63 816.07 # 67921 253.51 240.83 276.95
66940 719.68 683.70 786.26
66982 984.19 934.98 1,075.23
67412 809.74 769.25 884.64
67413 810.85 770.31 885.86
67922 325.81 309.52 355.95
# 67922 230.82 219.28 252.17
66983 679.06 645.11 741.88
66984 707.78 672.39 773.25
67414 1,224.98 1,163.73 1,338.29
67415 99.17 94.21 108.34
67923 539.66 512.68 589.58
# 67923 435.84 414.05 476.16
66985 704.02 668.82 769.14
66986 858.99 816.04 938.45
67420 1,530.78 1,454.24 1,672.38
67430 1,174.03 1,115.33 1,282.63
67924 560.65 532.62 612.51
# 67924 420.60 399.57 459.51
66990 86.12 81.81 94.08 67440 1,131.16 1,074.60 1,235.79 67930 352.61 334.98 385.23
67005 435.94 414.14 476.26
67010 502.82 477.68 549.33
67445 1,315.41 1,249.64 1,437.09
67450 1,173.76 1,115.07 1,282.33
# 67930 228.90 217.46 250.08
67935 569.69 541.21 622.39
67015 539.53 512.55 589.43
67025 676.64 642.81 739.23
67500 83.35 79.18 91.06
# 67500 74.51 70.78 81.40
# 67935 420.79 399.75 459.71
67938 239.31 227.34 261.44
# 67025 579.44 550.47 633.04 67505 82.27 78.16 89.88 # 67938 108.09 102.69 118.09
67027 789.42 749.95 862.44
67028 201.92 191.82 220.59
# 67505 72.99 69.34 79.74
67515 87.01 82.66 95.06
67950 551.52 523.94 602.53
# 67950 439.30 417.34 479.94
# 67028 158.18 150.27 172.81
67030 484.66 460.43 529.49
# 67515 79.50 75.53 86.86
67550 911.12 865.56 995.39
67961 551.51 523.93 602.52
# 67961 429.13 407.67 468.82
67031 358.59 340.66 391.76
# 67031 326.34 310.02 356.52
67560 926.13 879.82 1,011.79
67570 1,086.95 1,032.60 1,187.49
67966 717.80 681.91 784.20
# 67966 602.93 572.78 658.70
67036 890.46 845.94 972.83 67700 262.89 249.75 287.21 67971 681.52 647.44 744.56
67039 1,143.16 1,086.00 1,248.90
67040 1,316.59 1,250.76 1,438.37
# 67700 107.37 102.00 117.30
67710 222.53 211.40 243.11
67973 881.67 837.59 963.23
67974 877.89 834.00 959.10
67041 1,223.85 1,162.66 1,337.06
67042 1,399.33 1,329.36 1,528.76
# 67710 90.42 85.90 98.79
67715 233.42 221.75 255.01
67975 644.38 612.16 703.98
68020 111.81 106.22 122.15
67043 1,470.23 1,396.72 1,606.23 # 67715 101.76 96.67 111.17 # 68020 103.41 98.24 112.98
67101 723.74 687.55 790.68
# 67101 619.03 588.08 676.29
67800 119.61 113.63 130.67
# 67800 97.07 92.22 106.05
68040 61.79 58.70 67.51
# 68040 50.30 47.79 54.96
67105 667.08 633.73 728.79
# 67105 592.86 563.22 647.70
67801 152.66 145.03 166.78
# 67801 125.26 119.00 136.85
68100 167.59 159.21 183.09
# 68100 92.92 88.27 101.51
67107 1,120.59 1,064.56 1,224.24
67108 1,486.77 1,412.43 1,624.29
67805 189.79 180.30 207.35
# 67805 154.45 146.73 168.74
68110 217.82 206.93 237.97
# 68110 138.74 131.80 151.57
67110 807.80 767.41 882.52 67808 338.13 321.22 369.40 68115 303.14 287.98 331.18
# 67110 711.93 676.33 777.78
67112 1,227.52 1,166.14 1,341.06
67810 223.87 212.68 244.58
# 67810 89.12 84.66 97.36
# 68115 171.92 163.32 187.82
68130 515.07 489.32 562.72
67113 1,610.71 1,530.17 1,759.70
67115 455.66 432.88 497.81
67820 49.47 47.00 54.05
# 67820 51.23 48.67 55.97
# 68130 383.85 364.66 419.36
68135 146.67 139.34 160.24
67120 612.84 582.20 669.53 67825 121.31 115.24 132.53 # 68135 141.37 134.30 154.45
# 67120 511.66 486.08 558.99
67121 836.60 794.77 913.99
# 67825 113.35 107.68 123.83
67830 260.85 247.81 284.98
68200 40.18 38.17 43.90
# 68200 32.67 31.04 35.70
67141 482.44 458.32 527.07
# 67141 446.65 424.32 487.97
# 67830 128.75 122.31 140.66
67835 410.05 389.55 447.98
68320 683.04 648.89 746.22
# 68320 493.06 468.41 538.67
67145 485.58 461.30 530.50
# 67145 456.42 433.60 498.64
67840 271.11 257.55 296.18
# 67840 148.72 141.28 162.47
68325 610.26 579.75 666.71
68326 594.02 564.32 648.97
67208 553.60 525.92 604.81 67850 217.78 206.89 237.92 68328 662.95 629.80 724.27
# 67208 532.39 505.77 581.64
67210 642.59 610.46 702.03
# 67850 134.27 127.56 146.69
67875 168.91 160.46 184.53
68330 572.23 543.62 625.16
# 68330 423.34 402.17 462.50
# 67210 619.18 588.22 676.45
67218 1,294.82 1,230.08 1,414.59
# 67875 92.04 87.44 100.56
67880 430.03 408.53 469.81
68335 595.81 566.02 650.92
68340 516.96 491.11 564.78
67220 987.69 938.31 1,079.06 # 67880 338.13 321.22 369.40 # 68340 365.86 347.57 399.71
# 67220 937.32 890.45 1,024.02
67221 283.34 269.17 309.55
67882 528.08 501.68 576.93
# 67882 434.85 413.11 475.08
68360 501.79 476.70 548.21
# 68360 378.08 359.18 413.06
# 67221 205.14 194.88 224.11
67225 28.39 26.97 31.02
67900 611.23 580.67 667.77
# 67900 479.13 455.17 523.45
68362 603.66 573.48 659.50
68371 391.11 371.55 427.28
# 67225 26.62 25.29 29.08
67227 565.44 537.17 617.75
67901 658.41 625.49 719.31
# 67901 537.80 510.91 587.55
68400 275.94 262.14 301.46
# 68400 127.93 121.53 139.76
# 67227 526.12 499.81 574.78 67902 662.72 629.58 724.02 68420 312.09 296.49 340.96
67228 1,121.34 1,065.27 1,225.06
# 67228 977.75 928.86 1,068.19
67903 584.26 555.05 638.31
# 67903 464.97 441.72 507.98
# 68420 163.19 155.03 178.28
68440 102.44 97.32 111.92
67229 1,063.13 1,009.97 1,161.47
67250 733.75 697.06 801.62
67904 689.37 654.90 753.14
# 67904 549.75 522.26 600.60
# 68440 91.39 86.82 99.84
68500 899.75 854.76 982.97
67255 785.60 746.32 858.27 67906 480.45 456.43 524.89 68505 906.47 861.15 990.32
67311 552.83 525.19 603.97
67312 658.23 625.32 719.12
67908 464.98 441.73 507.99
# 67908 404.01 383.81 441.38
68510 436.51 414.68 476.88
# 68510 274.81 261.07 300.23
67314 619.24 588.28 676.52
67316 738.27 701.36 806.56
67909 512.21 486.60 559.59
# 67909 412.36 391.74 450.50
68520 639.05 607.10 698.17
68525 251.41 238.84 274.67
67318 648.55 616.12 708.54
67320 301.02 285.97 328.87
67911 513.61 487.93 561.12
67912 887.08 842.73 969.14
68530 421.35 400.28 460.32
# 68530 245.07 232.82 267.74
67331 284.85 270.61 311.20 # 67912 465.14 441.88 508.16 68540 860.63 817.60 940.24
67332 309.97 294.47 338.64
67334 281.12 267.06 307.12
67914 374.61 355.88 409.26
# 67914 270.79 257.25 295.84
68550 1,056.52 1,003.69 1,154.24
68700 555.71 527.92 607.11
CODES: 66821 - 68700
# - These amounts apply when the service is performed in a facility setting.
C - The payment for the technical component is capped at the OPPS amount.
Limiting charge applies to unassigned claims by non-participating providers. All CPT codes and modifiers are bolded.
All Current Procedural Terminology (CPT) codes and descriptors are copyrighted 2008 by the American Medical Association..

68705
68705
68720
68745
68750
68760
68760
68761
68761
68770
68801
68801
68810
68810
68811
68815
68815
68816
68816
68840
68840
68850
68850
69000
69000
69005
69005
69020
69020
69100
69100
69105
69105
69110
69110
69120
69140
69145
69145
69150
69155
69200
69200
69205
69210
69210
69220
69220
69222
69222
69300
69300
69310
69320
69400
69400
69401
69401
69405
69405
69420
69420
69421
69424
69424
69433
69433
69436
69440
69450
69501
69502
69505
69511
69530
69535
69540
69540
69550
69552
69554
69601
69602
69603
69604
69605
69610
69610
69620
69620
69631
69632
69633
69635
69636
69637
69641
69642
69643
69644
69645
69646
69650
69660
69661
69662
69666
69667
69670
69676
69700
69711
69714
69715
69717
69718
69720
69725
69740
69745
69801
69802
69805
69806
69820
69840
69905
69910
69915
69930
69950
69955
69960
69970
69990
70010
7001026
70010TC
70015
7001526
70015TC
70030
7003026
70030TC
70100
7010026
70100TC
70110
7011026
70110TC
70120
7012026
70120TC
70130
7013026
70130TC
70134
7013426
70134TC
70140
7014026
70140TC
70150
7015026
70150TC
70160
7016026
70160TC
70170
7017026
70170TC
70190
7019026
70190TC
70200
7020026
70200TC
70210
7021026
70210TC
70220
7022026
70220TC
70240
7024026
70240TC
70250
7025026
70250TC
70260
7026026
70260TC
70300
7030026
70300TC
70310
7031026
70310TC
70320
7032026
70320TC
70328
7032826
70328TC
70330
7033026
70330TC
70332
7033226
70332TC
70336
7033626
70336TC
70350
7035026
70350TC
70355
7035526
70355TC
70360
7036026
70360TC
70370
7037026
70370TC
70371
7037126
70371TC
70373
7037326
70373TC






California - MEDICARE CARRIER 01192 FSY2009 LOCALITY 18 FEE SCHEDULE PAGE: 31
PROCEDURE PAR NONPAR LIMITING
CODE/MOD FEE FEE CHARGE
PROCEDURE
CODE/MOD
PAR
FEE
NONPAR
FEE
LIMITING
CHARGE
PROCEDURE PAR
CODE/MOD FEE
NONPAR LIMITING
FEE CHARGE
68705 229.00 217.55 250.18
# 68705 155.22 147.46 169.58
68720 705.13 669.87 770.35
68745 708.86 673.42 774.43
68750 729.42 692.95 796.89
68760 194.23 184.52 212.20
# 68760 136.35 129.53 148.96
68761 140.59 133.56 153.59
# 68761 110.99 105.44 121.26
68770 545.84 518.55 596.33
68801 117.90 112.01 128.81
# 68801 101.11 96.05 110.46
68810 226.73 215.39 247.70
# 68810 178.57 169.64 195.09
68811 192.91 183.26 210.75
68815 431.87 410.28 471.82
# 68815 241.45 229.38 263.79
68816 676.61 642.78 739.20
# 68816 232.15 220.54 253.62
68840 117.90 112.01 128.81
# 68840 105.09 99.84 114.82
68850 65.66 62.38 71.74
# 68850 59.47 56.50 64.98
# 69000 118.32 112.40 129.26
69000 185.47 176.20 202.63
69005 217.00 206.15 237.07
# 69005 160.01 152.01 174.81
69020 239.17 227.21 261.29
# 69020 146.39 139.07 159.93
69100 110.81 105.27 121.06
# 69100 49.40 46.93 53.97
69105 146.61 139.28 160.17
# 69105 66.20 62.89 72.32
69110 472.55 448.92 516.26
# 69110 337.36 320.49 368.56
69120 411.18 390.62 449.21
69140 904.86 859.62 988.56
69145 399.39 379.42 436.33
# 69145 254.03 241.33 277.53
69150 1,078.67 1,024.74 1,178.45
69155 1,721.45 1,635.38 1,880.69
69200 127.41 121.04 139.20
# 69200 57.16 54.30 62.45
69205 104.06 98.86 113.69
69210 50.42 47.90 55.09
# 69210 32.75 31.11 35.78
69220 143.20 136.04 156.45
# 69220 64.12 60.91 70.05
69222 229.10 217.65 250.30
# 69222 142.51 135.38 155.69
69300 666.60 633.27 728.26
# 69300 491.20 466.64 536.64
69310 1,123.90 1,067.71 1,227.87
69320 1,591.03 1,511.48 1,738.20
69400 148.95 141.50 162.73
# 69400 63.68 60.50 69.58
69401 86.07 81.77 94.04
# 69401 51.17 48.61 55.90
69405 265.52 252.24 290.08
# 69405 197.92 188.02 216.22
69420 197.47 187.60 215.74
# 69420 123.24 117.08 134.64
69421 155.77 147.98 170.18
69424 134.68 127.95 147.14
# 69424 63.99 60.79 69.91
69433 204.74 194.50 223.68
# 69433 132.72 126.08 144.99
69436 168.65 160.22 184.25
69440 703.19 668.03 768.23
69450 554.60 526.87 605.90
69501 748.40 710.98 817.63
69502 993.55 943.87 1,085.45
69505 1,244.55 1,182.32 1,359.67
69511 1,278.42 1,214.50 1,396.68
69530 1,708.09 1,622.69 1,866.09
69535 2,745.66 2,608.38 2,999.64
69540 217.04 206.19 237.12
# 69540
69550
69552
69554
69601
69602
69603
69604
69605
69610
# 69610
69620
# 69620
69631
69632
69633
69635
69636
69637
69641
69642
69643
69644
69645
69646
69650
69660
69661
69662
69666
69667
69670
69676
69700
69711
69714
69715
69717
69718
69720
69725
69740
69745
69801
69802
69805
69806
69820
69840
69905
69910
69915
69930
69950
69955
69960
69970
69990
70010
7001026
70010 TC
70015
7001526
70015 TC
70030
7003026
70030 TC
70100
7010026
70100 TC
70110
7011026
70110 TC
70120
7012026
70120 TC
70130
131.77
1,077.41
1,623.50
2,544.09
1,071.98
1,116.61
1,314.11
1,151.96
1,616.08
402.47
302.17
718.96
501.59
903.67
1,105.44
1,066.33
1,261.28
1,428.42
1,422.23
1,068.22
1,374.61
1,255.34
1,532.76
1,502.79
1,593.19
813.54
953.29
1,245.49
1,191.30
826.04
829.07
965.59
855.92
711.59
889.27
1,104.20
1,366.87
1,166.13
1,432.90
1,204.96
1,937.65
1,202.77
1,279.42
768.30
1,068.51
1,076.69
970.92
887.54
937.02
945.31
1,047.96
1,575.23
1,270.18
1,860.99
2,040.98
1,972.35
2,205.56
220.22
197.42
65.13
132.30
163.75
66.88
96.87
32.44
9.32
23.11
35.02
9.70
25.32
45.30
13.65
31.65
38.25
9.70
28.55
62.95
125.18
1,023.54
1,542.33
2,416.89
1,018.38
1,060.78
1,248.40
1,094.36
1,535.28
382.35
287.06
683.01
476.51
858.49
1,050.17
1,013.01
1,198.22
1,357.00
1,351.12
1,014.81
1,305.88
1,192.57
1,456.12
1,427.65
1,513.53
772.86
905.63
1,183.22
1,131.74
784.74
787.62
917.31
813.12
676.01
844.81
1,048.99
1,298.53
1,107.82
1,361.26
1,144.71
1,840.77
1,142.63
1,215.45
729.89
1,015.08
1,022.86
922.37
843.16
890.17
898.04
995.56
1,496.47
1,206.67
1,767.94
1,938.93
1,873.73
2,095.28
209.21
187.55
61.87
125.69
155.56
63.54
92.03
30.82
8.85
21.95
33.27
9.22
24.05
43.04
12.97
30.07
36.34
9.22
27.12
59.80
143.96
1,177.07
1,773.68
2,779.42
1,171.14
1,219.90
1,435.66
1,258.51
1,765.57
439.70
330.12
785.46
547.99
987.26
1,207.70
1,164.96
1,377.95
1,560.55
1,553.79
1,167.03
1,501.76
1,371.46
1,674.54
1,641.80
1,740.56
888.79
1,041.47
1,360.70
1,301.50
902.45
905.76
1,054.91
935.09
777.41
971.53
1,206.34
1,493.31
1,273.99
1,565.45
1,316.42
2,116.89
1,314.02
1,397.77
839.37
1,167.34
1,176.29
1,060.73
969.63
1,023.70
1,032.75
1,144.89
1,720.94
1,387.67
2,033.13
2,229.77
2,154.79
2,409.57
240.59
215.68
71.15
144.54
178.89
73.07
105.83
35.44
10.18
25.24
38.26
10.60
27.66
49.50
14.92
34.58
41.79
10.60
31.19
68.77
7013026 18.65
70130 TC 44.31
70134 53.68
7013426 18.65
70134 TC 35.03
70140 34.21
7014026 10.07
70140 TC 24.13
70150 49.06
7015026 14.03
70150 TC 35.03
70160 36.85
7016026 9.32
70160 TC 27.53
70170 61.34
7017026 16.41
70170 TC 44.49
70190 40.70
7019026 11.27
70190 TC 29.44
70200 50.69
7020026 15.22
70200 TC 35.47
70210 34.34
7021026 9.32
70210 TC 25.02
70220 44.70
7022026 13.21
70220 TC 31.49
70240 33.63
7024026 10.52
70240 TC 23.11
70250 41.39
7025026 12.84
70250 TC 28.55
70260 54.85
7026026 18.21
70260 TC 36.64
70300 16.11
7030026 5.81
70300 TC 10.30
70310 39.13
7031026 8.95
70310 TC 30.18
C 70320 50.36
7032026 12.08
C 70320 TC 38.27
70328 34.14
7032826 9.70
70328 TC 24.44
70330 54.49
7033026 13.28
70330 TC 41.21
70332 97.23
7033226 28.81
70332 TC 68.43
C 70336 500.67
7033626 81.45
C 70336 TC 419.22
70350 23.16
7035026 9.32
70350 TC 13.83
70355 25.75
7035526 10.89
70355 TC 14.86
70360 31.11
7036026 9.32
70360 TC 21.79
70370 86.35
7037026 17.16
70370 TC 69.19
70371 110.84
7037126 44.63
70371 TC 66.22
70373 92.75
7037326 22.40
70373 TC 70.35
17.72 20.38
42.09 48.40
51.00 58.65
17.72 20.38
33.28 38.27
32.50 37.38
9.57 11.01
22.92 26.36
46.61 53.60
13.33 15.33
33.28 38.27
35.01 40.26
8.85 10.18
26.15 30.07
58.27 67.01
15.59 17.93
42.27 48.61
38.67 44.47
10.71 12.32
27.97 32.17
48.16 55.38
14.46 16.63
33.70 38.76
32.62 37.51
8.85 10.18
23.77 27.34
42.47 48.84
12.55 14.43
29.92 34.41
31.95 36.74
9.99 11.49
21.95 25.24
39.32 45.22
12.20 14.03
27.12 31.19
52.11 59.93
17.30 19.90
34.81 40.03
15.30 17.60
5.52 6.35
9.79 11.26
37.17 42.75
8.50 9.78
28.67 32.97
47.84 55.02
11.48 13.20
36.36 41.81
32.43 37.29
9.22 10.60
23.22 26.70
51.77 59.54
12.62 14.51
39.15 45.02
92.37 106.23
27.37 31.48
65.01 74.76
475.64 546.99
77.38 88.99
398.26 458.00
22.00 25.30
8.85 10.18
13.14 15.11
24.46 28.13
10.35 11.90
14.12 16.24
29.55 33.98
8.85 10.18
20.70 23.81
82.03 94.33
16.30 18.75
65.73 75.59
105.30 121.10
42.40 48.76
62.91 72.35
88.11 101.33
21.28 24.47
66.83 76.85
CODES: 68705 - 70373TC
# - These amounts apply when the service is performed in a facility setting.
C - The payment for the technical component is capped at the OPPS amount.
Limiting charge applies to unassigned claims by non-participating providers. All CPT codes and modifiers are bolded.
All Current Procedural Terminology (CPT) codes and descriptors are copyrighted 2008 by the American Medical Association.

70380
7038026
70380TC
70390
7039026
70390TC
70450
7045026
70450TC
70460
7046026
70460TC
70470
7047026
70470TC
70480
7048026
70480TC
70481
7048126
70481TC
70482
7048226
70482TC
70486
7048626
70486TC
70487
7048726
70487TC
70488
7048826
70488TC
70490
7049026
70490TC
70491
7049126
70491TC
70492
7049226
70492TC
70496
7049626
70496TC
70498
7049826
70498TC
70540
7054026
70540TC
70542
7054226
70542TC
70543
7054326
70543TC
70544
7054426
70544TC
70545
7054526
70545TC
70546
7054626
70546TC
70547
7054726
70547TC
70548
7054826
70548TC
70549
7054926
70549TC
70551
7055126
70551TC
70552
7055226
70552TC
70553
7055326
70553TC
70554
7055426
70554TC
7055526
70555TC
7055726
7055826
7055926
71010
7101026
71010TC
71015
7101526
71015TC
71020
7102026
71020TC
71021
7102126
71021TC
71022
7102226
71022TC
71023
7102326
71023TC
71030
7103026
71030TC
71034
7103426
71034TC
71035
7103526
71035TC
71040
7104026
71040TC
71060
7106026
71060TC
71090
7109026
71090TC
71100
7110026
71100TC
71101
7110126
71101TC
71110
7111026
71110TC
71111
7111126
71111TC
71120
7112026
71120TC
71130
7113026
71130TC
71250
7125026
71250TC
71260
7126026
71260TC
71270
7127026
71270TC
71275
7127526
71275TC
71550
7155026
71550TC
71551
7155126
71551TC
71552
7155226
71552TC
71555
7155526
71555TC
72010
7201026
72010TC
72020
7202026
72020TC
72040
7204026
72040TC
72050
7205026
72050TC
72052
7205226
72052TC
72069
7206926
72069TC
72070
7207026
72070TC
72072
7207226
72072TC
72074
7207426
72074TC
72080
7208026
72080TC
72090
7209026
72090TC
72100
7210026
72100TC
72110
7211026
72110TC
72114
7211426
72114TC
72120
7212026
72120TC
72125
7212526
72125TC
72126
7212626
72126TC
72127
7212726
72127TC
72128
7212826
72128TC
72129
7212926
72129TC
72130






California - MEDICARE CARRIER 01192 FSY2009 LOCALITY 18 FEE SCHEDULE PAGE: 32
PROCEDURE PAR NONPAR CHARGE
CODE/MOD FEE FEE LIMIT
PROCEDURE PAR NONPAR CHARGE
CODE/MOD FEE FEE LIMIT
PROCEDURE PAR NONPAR CHARGE
CODE/MOD FEE FEE LIMIT
70380 42.74 40.60 46.69
7038026 9.32 8.85 10.18
C 70551 TC 420.42 399.40 459.31
C 70552 613.51 582.83 670.25
C 71270TC 411.12 390.56 449.14
C 71275 532.71 506.07 581.98
70380 TC 33.41 31.74 36.50 7055226 98.31 93.39 107.40 7127526 106.51 101.18 116.36
70390 116.12 110.31 126.86
7039026 21.03 19.98 22.98
C 70552 TC 515.20 489.44 562.86
C 70553 775.00 736.25 846.69
C 71275TC 426.20 404.89 465.62
C 71550 501.92 476.82 548.34
70390 TC 95.09 90.34 103.89
70450 257.70 244.82 281.54
7055326 129.94 123.44 141.96
C 70553 TC 645.05 612.80 704.72
7155026 79.97 75.97 87.37
C 71550 TC 421.95 400.85 460.98
7045026 47.21 44.85 51.58 70554 730.63 694.10 798.22 C 71551 612.60 581.97 669.27
70450 TC 210.48 199.96 229.95
70460 333.13 316.47 363.94
7055426 117.47 111.60 128.34
70554 TC 613.16 582.50 669.88
7155126 94.67 89.94 103.43
C 71551 TC 517.93 492.03 565.83
7046026 62.43 59.31 68.21
70460 TC 270.70 257.17 295.75
7055526 141.85 134.76 154.97
70555 TC 604.41 574.19 660.32
C 71552 778.26 739.35 850.25
7155226 125.31 119.04 136.90
70470 403.88 383.69 441.24
7047026 70.19 66.68 76.68
7055726 161.13 153.07 176.03
7055826 175.62 166.84 191.87
C 71552TC 652.95 620.30 713.35
C 71555 616.87 586.03 673.93
70470 TC 333.70 317.02 364.57 7055926 178.85 169.91 195.40 7155526 100.76 95.72 110.08
C 70480 305.97 290.67 334.27
7048026 70.56 67.03 77.08
71010 27.51 26.13 30.05
7101026 9.70 9.22 10.60
C 71555TC 516.11 490.30 563.85
72010 79.30 75.34 86.64
C 70480 TC 235.41 223.64 257.19
C 70481 448.55 426.12 490.04
71010 TC 17.81 16.92 19.46
71015 33.94 32.24 37.08
7201026 23.66 22.48 25.85
72010TC 55.64 52.86 60.79
7048126 76.09 72.29 83.13 7101526 11.27 10.71 12.32 72020 27.27 25.91 29.80
C 70481 TC 372.47 353.85 406.93
C 70482 491.95 467.35 537.45
71015 TC 22.67 21.54 24.77
71020 36.66 34.83 40.05
7202026 8.57 8.14 9.36
72020TC 18.69 17.76 20.42
7048226 79.60 75.62 86.96
C 70482 TC 412.35 391.73 450.49
7102026 12.08 11.48 13.20
71020 TC 24.58 23.35 26.85
72040 42.40 40.28 46.32
7204026 12.08 11.48 13.20
C 70486 297.61 282.73 325.14
7048626 62.81 59.67 68.62
71021 44.13 41.92 48.21
7102126 14.40 13.68 15.73
72040TC 30.32 28.80 33.12
72050 60.06 57.06 65.62
C 70486 TC 234.80 223.06 256.52 71021 TC 29.73 28.24 32.48 7205026 16.79 15.95 18.34
70487 401.66 381.58 438.82
7048726 72.20 68.59 78.88
71022 53.14 50.48 58.05
7102226 16.79 15.95 18.34
72050TC 43.27 41.11 47.28
72052 75.48 71.71 82.47
70487 TC 329.46 312.99 359.94
C 70488 489.93 465.43 535.24
71022 TC 36.35 34.53 39.71
71023 77.42 73.55 84.58
7205226 19.84 18.85 21.68
72052TC 55.64 52.86 60.79
7048826 78.03 74.13 85.25 7102326 21.18 20.12 23.14 72069 40.06 38.06 43.77
C 70488 TC 411.90 391.31 450.01
C 70490 305.65 290.37 333.93
71023 TC 56.24 53.43 61.44
71030 53.58 50.90 58.54
7206926 12.08 11.48 13.20
72069TC 27.97 26.57 30.56
7049026 71.01 67.46 77.58
C 70490 TC 234.65 222.92 256.36
7103026 16.79 15.95 18.34
71030 TC 36.80 34.96 40.20
72070 38.87 36.93 42.47
7207026 12.08 11.48 13.20
70491 394.06 374.36 430.51
7049126 76.09 72.29 83.13
71034 106.77 101.43 116.64
7103426 27.13 25.77 29.64
72070TC 26.79 25.45 29.27
72072 44.46 42.24 48.58
70491 TC 317.97 302.07 347.38 71034 TC 79.64 75.66 87.01 7207226 12.08 11.48 13.20
70492 480.01 456.01 524.41
7049226 79.60 75.62 86.96
71035 39.88 37.89 43.57
7103526 10.14 9.63 11.07
72072TC 32.38 30.76 35.37
72074 52.26 49.65 57.10
70492 TC 400.41 380.39 437.45
C 70496 522.78 496.64 571.14
71035 TC 29.74 28.25 32.49
71040 110.68 105.15 120.92
7207426 12.08 11.48 13.20
72074TC 40.18 38.17 43.90
7049626 97.18 92.32 106.17 7104026 31.92 30.32 34.87 72080 40.64 38.61 44.40
C 70496 TC 425.59 404.31 464.96
C 70498 523.22 497.06 571.62
71040 TC 78.75 74.81 86.03
71060 161.88 153.79 176.86
7208026 12.08 11.48 13.20
72080TC 28.55 27.12 31.19
7049826 97.63 92.75 106.66
C 70498 TC 425.59 404.31 464.96
7106026 40.58 38.55 44.33
71060 TC 121.29 115.23 132.51
72090 53.49 50.82 58.44
7209026 15.66 14.88 17.11
C 70540 496.18 471.37 542.08
7054026 74.08 70.38 80.94
71090 110.54 105.01 120.76
7109026 32.34 30.72 35.33
72090TC 37.83 35.94 41.33
72100 44.61 42.38 48.74
C 70540 TC 422.10 401.00 461.15 71090 TC 78.83 74.89 86.12 7210026 12.08 11.48 13.20
C 70542 606.70 576.37 662.83
7054226 88.92 84.47 97.14
71100 37.54 35.66 41.01
7110026 12.08 11.48 13.20
72100TC 32.53 30.90 35.54
72110 62.27 59.16 68.03
C 70542 TC 517.78 491.89 565.67
C 70543 768.74 730.30 839.85
71100 TC 25.46 24.19 27.82
71101 45.17 42.91 49.35
7211026 16.79 15.95 18.34
72110TC 45.48 43.21 49.69
7054326 118.08 112.18 129.01 7110126 14.40 13.68 15.73 72114 81.67 77.59 89.23
C 70543 TC 650.66 618.13 710.85
C 70544 486.53 462.20 531.53
71101 TC 30.76 29.22 33.60
71110 46.78 44.44 51.11
7211426 19.84 18.85 21.68
72114TC 61.83 58.74 67.55
7054426 65.94 62.64 72.04
C 70544 TC 420.58 399.55 459.48
7111026 14.40 13.68 15.73
71110 TC 32.38 30.76 35.37
72120 56.24 53.43 61.44
7212026 12.08 11.48 13.20
C 70545 582.36 553.24 636.23
7054526 65.94 62.64 72.04
71111 59.99 56.99 65.54
7111126 17.16 16.30 18.75
72120TC 44.15 41.94 48.23
C 72125 298.04 283.14 325.61
C 70545 TC 516.42 490.60 564.19 71111 TC 42.83 40.69 46.79 7212526 64.00 60.80 69.92
C 70546 753.07 715.42 822.73
7054626 99.06 94.11 108.23
71120 37.68 35.80 41.17
7112026 10.89 10.35 11.90
C 72125TC 234.04 222.34 255.69
72126 403.48 383.31 440.81
C 70546 TC 654.01 621.31 714.51
C 70547 486.37 462.05 531.36
71120 TC 26.79 25.45 29.27
71130 43.29 41.13 47.30
7212626 67.14 63.78 73.35
72126TC 336.35 319.53 367.46
7054726 65.94 62.64 72.04 7113026 12.08 11.48 13.20 C 72127 480.87 456.83 525.35
C 70547 TC 420.43 399.41 459.32
C 70548 582.66 553.53 636.56
71130 TC 31.20 29.64 34.09
C 71250 298.04 283.14 325.61
7212726 69.75 66.26 76.20
C 72127 TC 411.12 390.56 449.14
7054826 65.94 62.64 72.04
C 70548 TC 516.72 490.88 564.51
7125026 64.00 60.80 69.92
C 71250 TC 234.04 222.34 255.69
C 72128 298.04 283.14 325.61
7212826 64.00 60.80 69.92
C 70549 753.07 715.42 822.73
7054926 99.06 94.11 108.23
71260 404.24 384.03 441.63
7126026 68.33 64.91 74.65
C 72128TC 234.04 222.34 255.69
72129 403.93 383.73 441.29
C 70549 TC 654.01 621.31 714.51 71260 TC 335.91 319.11 366.98 7212926 67.58 64.20 73.83
C 70551 501.87 476.78 548.30
7055126 81.45 77.38 88.99
C 71270 487.21 462.85 532.28
7127026 76.09 72.29 83.13
72129TC 336.35 319.53 367.46
C 72130 481.31 457.24 525.83
CODES: 70380 - 72130
# - These amounts apply when the service is performed in a facility setting.
C - The payment for the technical component is capped at the OPPS amount.
Limiting charge applies to unassigned claims by non-participating providers. All CPT codes and modifiers are bolded.
All Current Procedural Terminology (CPT) codes and descriptors are copyrighted 2008 by the American Medical Association..

7213026
72130TC
72131
7213126
72131TC
72132
7213226
72132TC
72133
7213326
72133TC
72141
7214126
72141TC
72142
7214226
72142TC
72146
7214626
72146TC
72147
7214726
72147TC
72148
7214826
72148TC
72149
7214926
72149TC
72156
7215626
72156TC
72157
7215726
72157TC
72158
7215826
72158TC
72170
7217026
72170TC
72190
7219026
72190TC
72191
7219126
72191TC
72192
7219226
72192TC
72193
7219326
72193TC
72194
7219426
72194TC
72195
7219526
72195TC
72196
7219626
72196TC
72197
7219726
72197TC
72198
7219826
72198TC
72200
7220026
72200TC
72202
7220226
72202TC
72220
7222026
72220TC
72240
7224026
72240TC
72255
7225526
72255TC
72265
7226526
72265TC
72270
7227026
72270TC
72275
7227526
72275TC
72285
7228526
72285TC
72291
7229126
72292
7229226
72295
7229526
72295TC
73000
7300026
73000TC
73010
7301026
73010TC
73020
7302026
73020TC
73030
7303026
73030TC
73040
7304026
73040TC
73050
7305026
73050TC
73060
7306026
73060TC
73070
7307026
73070TC
73080
7308026
73080TC
73085
7308526
73085TC
73090
7309026
73090TC
73092
7309226
73092TC
73100
7310026
73100TC
73110
7311026
73110TC
73115
7311526
73115TC
73120
7312026
73120TC
73130
7313026
73130TC
73140
7314026
73140TC
73200
7320026
73200TC
73201
7320126
73201TC
73202
7320226
73202TC
73206
7320626
73206TC
73218
7321826
73218TC
73219
7321926
73219TC
73220
7322026
73220TC
73221
7322126
73221TC
73222
7322226
73222TC
73223
7322326
73223TC
73500
7350026
73500TC
73510
7351026
73510TC
73520
7352026
73520TC
73525
7352526
73525TC
73530
7353026
73530TC
73540
7354026
73540TC
73542
7354226
73542TC
73550
7355026
73550TC
73560
7356026
73560TC
73562
7356226
73562TC
73564
7356426
73564TC
73565
7356526
73565TC
73580
7358026
73580TC
73590
7359026
73590TC
73592
7359226
73592TC






California - MEDICARE CARRIER 01192 FSY2009 LOCALITY 18 FEE SCHEDULE PAGE: 33
PROCEDURE PAR NONPAR LIMITING
CODE/MOD FEE FEE CHARGE
PROCEDURE PAR NONPAR LIMITING
CODE/MOD FEE FEE CHARGE
PROCEDURE PAR NONPAR LIMITING
CODE/MOD FEE FEE CHARGE
7213026 70.19 66.68 76.68
C 72130 TC 411.12 390.56 449.14
72240 183.51 174.33 200.48
7224026 49.91 47.41 54.52
7314026 7.38 7.01 8.06
73140TC 25.76 24.47 28.14
C 72131 298.04 283.14 325.61 72240 TC 133.61 126.93 145.97 C 73200 294.69 279.96 321.95
7213126 64.00 60.80 69.92
C 72131 TC 234.04 222.34 255.69
72255 167.18 158.82 182.64
7225526 48.58 46.15 53.07
7320026 60.05 57.05 65.61
C 73200TC 234.65 222.92 256.36
72132 403.48 383.31 440.81
7213226 67.58 64.20 73.83
72255 TC 118.60 112.67 129.57
72265 170.80 162.26 186.60
73201 383.59 364.41 419.07
7320126 64.00 60.80 69.92
72132 TC 335.91 319.11 366.98 7226526 45.58 43.30 49.80 73201TC 319.59 303.61 349.15
C 72133 481.31 457.24 525.83
7213326 70.19 66.68 76.68
72265 TC 125.23 118.97 136.82
72270 266.25 252.94 290.88
C 73202 479.32 455.35 523.65
7320226 67.14 63.78 73.35
C 72133 TC 411.12 390.56 449.14
C 72141 506.94 481.59 553.83
7227026 73.32 69.65 80.10
72270 TC 192.92 183.27 210.76
C 73202 TC 412.19 391.58 450.32
C 73206 526.95 500.60 575.69
7214126 87.73 83.34 95.84
C 72141 TC 419.22 398.26 458.00
72275 119.14 113.18 130.16
7227526 38.97 37.02 42.57
7320626 101.20 96.14 110.56
C 73206TC 425.75 404.46 465.13
C 72142 620.82 589.78 678.25 72275 TC 80.16 76.15 87.57 C 73218 495.89 471.10 541.77
7214226 105.62 100.34 115.39
C 72142 TC 515.20 489.44 562.86
72285 203.85 193.66 222.71
7228526 60.60 57.57 66.21
7321826 73.63 69.95 80.44
C 73218 TC 422.25 401.14 461.31
C 72146 507.08 481.73 553.99
7214626 88.17 83.76 96.32
72285 TC 143.25 136.09 156.50
72291 77.34 73.47 84.49
C 73219 607.14 576.78 663.30
7321926 88.92 84.47 97.14
C 72146 TC 418.91 397.96 457.65 7229126 74.62 70.89 81.52 C 73219TC 518.22 492.31 566.16
C 72147 620.36 589.34 677.74
7214726 106.07 100.77 115.89
72292 79.88 75.89 87.27
7229226 77.70 73.82 84.89
C 73220 769.34 730.87 840.50
7322026 118.53 112.60 129.49
C 72147 TC 514.29 488.58 561.87
C 72148 500.37 475.35 546.65
72295 182.79 173.65 199.70
7229526 44.39 42.17 48.50
C 73220TC 650.81 618.27 711.01
C 73221 496.02 471.22 541.90
7214826 81.45 77.38 88.99
C 72148 TC 418.91 397.96 457.65
72295 TC 138.40 131.48 151.20
73000 31.62 30.04 34.55
7322126 74.08 70.38 80.94
C 73221TC 421.95 400.85 460.98
C 72149 613.51 582.83 670.25 7300026 8.95 8.50 9.78 C 73222 606.40 576.08 662.49
7214926 98.31 93.39 107.40
C 72149 TC 515.20 489.44 562.86
73000 TC 22.67 21.54 24.77
73010 32.44 30.82 35.44
7322226 88.92 84.47 97.14
C 73222 TC 517.48 491.61 565.35
C 72156 786.40 747.08 859.14
7215626 141.21 134.15 154.27
7301026 9.32 8.85 10.18
73010 TC 23.11 21.95 25.24
C 73223 768.44 730.02 839.52
7322326 118.08 112.18 129.01
C 72156 TC 645.19 612.93 704.87 73020 26.83 25.49 29.31 C 73223TC 650.36 617.84 710.52
C 72157 785.94 746.64 858.64
7215726 141.65 134.57 154.76
7302026 8.13 7.72 8.88
73020 TC 18.69 17.76 20.42
73500 28.90 27.46 31.58
7350026 9.32 8.85 10.18
C 72157 TC 644.28 612.07 703.88
C 72158 774.70 735.97 846.37
73030 34.28 32.57 37.46
7303026 10.14 9.63 11.07
73500TC 19.58 18.60 21.39
73510 42.03 39.93 45.92
7215826 129.50 123.03 141.48
C 72158 TC 645.19 612.93 704.87
73030 TC 24.13 22.92 26.36
73040 123.74 117.55 135.18
7351026 11.71 11.12 12.79
73510 TC 30.32 28.80 33.12
72170 29.79 28.30 32.55 7304026 29.69 28.21 32.44 73520 45.23 42.97 49.42
7217026 9.32 8.85 10.18
72170 TC 20.46 19.44 22.36
73040 TC 94.05 89.35 102.75
73050 41.21 39.15 45.02
7352026 14.03 13.33 15.33
73520TC 31.20 29.64 34.09
72190 45.56 43.28 49.77
7219026 11.71 11.12 12.79
7305026 11.33 10.76 12.37
73050 TC 29.88 28.39 32.65
73525 111.22 105.66 121.51
7352526 29.98 28.48 32.75
72190 TC 33.85 32.16 36.98 73060 33.46 31.79 36.56 73525TC 81.24 77.18 88.76
C 72191 526.37 500.05 575.06
7219126 100.32 95.30 109.60
7306026 9.32 8.85 10.18
73060 TC 24.13 22.92 26.36
73530 40.33 38.31 44.06
7353026 16.04 15.24 17.53
C 72191 TC 426.05 404.75 465.46
C 72192 294.38 279.66 321.61
73070 30.80 29.26 33.65
7307026 8.13 7.72 8.88
73530TC 23.88 22.69 26.09
73540 42.10 40.00 46.00
7219226 60.49 57.47 66.09
C 72192 TC 233.89 222.20 255.53
73070 TC 22.67 21.54 24.77
73080 39.64 37.66 43.31
7354026 10.89 10.35 11.90
73540TC 31.20 29.64 34.09
72193 383.71 364.52 419.20 7308026 9.32 8.85 10.18 73542 90.12 85.61 98.45
7219326 64.00 60.80 69.92
72193 TC 319.71 303.72 349.28
73080 TC 30.32 28.80 33.12
73085 111.37 105.80 121.67
7354226 30.09 28.59 32.88
73542 TC 60.03 57.03 65.58
C 72194 478.72 454.78 523.00
7219426 67.14 63.78 73.35
7308526 29.25 27.79 31.96
73085 TC 82.12 78.01 89.71
73550 32.57 30.94 35.58
7355026 9.32 8.85 10.18
C 72194 TC 411.58 391.00 449.65 73090 31.18 29.62 34.06 73550TC 23.25 22.09 25.40
C 72195 501.47 476.40 547.86
7219526 79.97 75.97 87.37
7309026 8.51 8.08 9.29
73090 TC 22.67 21.54 24.77
73560 32.44 30.82 35.44
7356026 9.32 8.85 10.18
C 72195 TC 421.49 400.42 460.48
C 72196 612.88 582.24 669.58
73092 32.06 30.46 35.03
7309226 8.51 8.08 9.29
73560TC 23.11 21.95 25.24
73562 39.14 37.18 42.76
7219626 95.55 90.77 104.39
C 72196 TC 517.33 491.46 565.18
73092 TC 23.55 22.37 25.73
73100 32.50 30.88 35.51
7356226 10.14 9.63 11.07
73562 TC 28.99 27.54 31.67
C 72197 774.32 735.60 845.94 7310026 8.95 8.50 9.78 73564 45.50 43.23 49.71
7219726 124.42 118.20 135.93
C 72197 TC 649.90 617.41 710.02
73100 TC 23.55 22.37 25.73
73110 39.06 37.11 42.68
7356426 12.08 11.48 13.20
73564TC 33.41 31.74 36.50
C 72198 615.61 584.83 672.55
7219826 99.50 94.53 108.71
7311026 9.32 8.85 10.18
73110 TC 29.74 28.25 32.49
73565 34.65 32.92 37.86
7356526 9.77 9.28 10.67
C 72198 TC 516.11 490.30 563.85 73115 118.30 112.39 129.25 73565TC 24.88 23.64 27.19
72200 33.32 31.65 36.40
7220026 9.32 8.85 10.18
7311526 29.69 28.21 32.44
73115 TC 88.61 84.18 96.81
73580 139.63 132.65 152.55
7358026 29.98 28.48 32.75
72200 TC 24.00 22.80 26.22
72202 40.39 38.37 44.13
73120 30.74 29.20 33.58
7312026 8.51 8.08 9.29
73580 TC 109.65 104.17 119.80
73590 31.11 29.55 33.98
7220226 10.52 9.99 11.49
72202 TC 29.88 28.39 32.65
73120 TC 22.23 21.12 24.29
73130 35.53 33.75 38.81
7359026 9.32 8.85 10.18
73590 TC 21.79 20.70 23.81
72220 33.90 32.21 37.04 7313026 9.32 8.85 10.18 73592 32.06 30.46 35.03
7222026 9.32 8.85 10.18
72220 TC 24.58 23.35 26.85
73130 TC 26.21 24.90 28.64
73140 33.14 31.48 36.20
7359226 8.51 8.08 9.29
73592TC 23.55 22.37 25.73
CODES: 7213026 - 73592TC
# - These amounts apply when the service is performed in a facility setting.
C - The payment for the technical component is capped at the OPPS amount.
Limiting charge applies to unassigned claims by non-participating providers. All CPT codes and modifiers are bolded.
All Current Procedural Terminology (CPT) codes and descriptors are copyrighted 2008 by the American Medical Association.

73600
7360026
73600TC
73610
7361026
73610TC
73615
7361526
73615TC
73620
7362026
73620TC
73630
7363026
73630TC
73650
7365026
73650TC
73660
7366026
73660TC
73700
7370026
73700TC
73701
7370126
73701TC
73702
7370226
73702TC
73706
7370626
73706TC
73718
7371826
73718TC
73719
7371926
73719TC
73720
7372026
73720TC
73721
7372126
73721TC
73722
7372226
73722TC
73723
7372326
73723TC
73725
7372526
73725TC
74000
7400026
74000TC
74010
7401026
74010TC
74020
7402026
74020TC
74022
7402226
74022TC
74150
7415026
74150TC
74160
7416026
74160TC
74170
7417026
74170TC
74175
7417526
74175TC
74181
7418126
74181TC
74182
7418226
74182TC
74183
7418326
74183TC
74185
7418526
74185TC
74190
7419026
74190TC
74210
7421026
74210TC
74220
7422026
74220TC
74230
7423026
74230TC
74235
7423526
74235TC
74240
7424026
74240TC
74241
7424126
74241TC
74245
7424526
74245TC
74246
7424626
74246TC
74247
7424726
74247TC
74249
7424926
74249TC
74250
7425026
74250TC
74251
7425126
74251TC
74260
7426026
74260TC
74270
7427026
74270TC
74280
7428026
74280TC
74283
7428326
74283TC
74290
7429026
74290TC
74291
7429126
74291TC
7430026
7430126
74305
7430526
74305TC
74320
7432026
74320TC
74327
7432726
74327TC
74328
7432826
74328TC
74329
7432926
74329TC
74330
7433026
74330TC
74340
7434026
74340TC
74355
7435526
74355TC
74360
7436026
74360TC
74363
7436326
74363TC
74400
7440026
74400TC
74410
7441026
74410TC
74415
7441526
74415TC
74420
7442026
74420TC
74425
7442526
74425TC
74430
7443026
74430TC
74440
7444026
74440TC
74445
7444526
74445TC
74450
7445026
74450TC
74455
7445526
74455TC
74470
7447026
74470TC
74475
7447526
74475TC
74480
7448026
74480TC
74485
7448526
74485TC
74710
7471026
74710TC
74740
7474026
74740TC
74742
7474226
74742TC
74775






California - MEDICARE CARRIER 01192 FSY2009 LOCALITY 18 FEE SCHEDULE PAGE: 34
PROCEDURE PAR NONPAR CHARGE
CODE/MOD FEE FEE LIMIT
PROCEDURE PAR NONPAR CHARGE
CODE/MOD FEE FEE LIMIT
PROCEDURE PAR NONPAR CHARGE
CODE/MOD FEE FEE LIMIT
73600 30.74 29.20 33.58
7360026 8.51 8.08 9.29
C 74175 TC 426.35 405.03 465.78
C 74181 501.30 476.24 547.68
74320 TC 103.45 98.28 113.02
74327 151.40 143.83 165.40
73600 TC 22.23 21.12 24.29 7418126 80.41 76.39 87.85 7432726 39.08 37.13 42.70
73610 35.53 33.75 38.81
7361026 9.32 8.85 10.18
C 74181 TC 420.89 399.85 459.83
C 74182 613.33 582.66 670.06
74327TC 112.32 106.70 122.71
74328 186.31 176.99 203.54
73610 TC 26.21 24.90 28.64
73615 114.31 108.59 124.88
7418226 95.55 90.77 104.39
C 74182 TC 517.78 491.89 565.67
7432826 39.08 37.13 42.70
74328TC 146.90 139.56 160.49
7361526 29.54 28.06 32.27 C 74183 774.32 735.60 845.94 74329 184.90 175.66 202.01
73615 TC 84.77 80.53 92.61
73620 29.85 28.36 32.61
7418326 124.42 118.20 135.93
C 74183 TC 649.90 617.41 710.02
7432926 39.08 37.13 42.70
74329TC 145.37 138.10 158.82
7362026 8.51 8.08 9.29
73620 TC 21.35 20.28 23.32
C 74185 615.46 584.69 672.39
7418526 99.50 94.53 108.71
74330 197.36 187.49 215.61
7433026 49.97 47.47 54.59
73630 35.09 33.34 38.34
7363026 9.32 8.85 10.18
C 74185 TC 515.96 490.16 563.68
74190 87.98 83.58 96.12
74330TC 146.90 139.56 160.49
74340 152.60 144.97 166.72
73630 TC 25.76 24.47 28.14 7419026 26.55 25.22 29.00 7434026 29.69 28.21 32.44
73650 30.29 28.78 33.10
7365026 8.51 8.08 9.29
74190 TC 60.88 57.84 66.52
74210 89.18 84.72 97.43
74340TC 122.21 116.10 133.52
74355 164.90 156.66 180.16
73650 TC 21.79 20.70 23.81
73660 31.38 29.81 34.28
7421026 20.28 19.27 22.16
74210 TC 68.90 65.46 75.28
7435526 42.22 40.11 46.13
74355TC 122.21 116.10 133.52
7366026 6.94 6.59 7.58 74220 100.88 95.84 110.22 74360 177.73 168.84 194.17
73660 TC 24.44 23.22 26.70
C 73700 294.69 279.96 321.95
7422026 25.36 24.09 27.70
74220 TC 75.52 71.74 82.50
7436026 31.02 29.47 33.89
74360TC 146.90 139.56 160.49
7370026 60.05 57.05 65.61
C 73700 TC 234.65 222.92 256.36
74230 103.36 98.19 112.92
7423026 29.32 27.85 32.03
74363 331.36 314.79 362.01
7436326 49.22 46.76 53.77
73701 386.24 366.93 421.97
7370126 64.44 61.22 70.40
74230 TC 74.05 70.35 80.90
74235 188.36 178.94 205.78
74363TC 281.54 267.46 307.58
74400 127.76 121.37 139.58
73701 TC 321.79 305.70 351.56 7423526 67.34 63.97 73.57 7440026 26.93 25.58 29.42
C 73702 479.77 455.78 524.15
7370226 67.58 64.20 73.83
74235 TC 120.85 114.81 132.03
74240 124.09 117.89 135.57
74400 TC 100.83 95.79 110.16
74410 134.83 128.09 147.30
C 73702 TC 412.19 391.58 450.32
C 73706 532.26 505.65 581.50
7424026 38.26 36.35 41.80
74240 TC 85.82 81.53 93.76
7441026 27.37 26.00 29.90
74410TC 107.46 102.09 117.40
7370626 106.35 101.03 116.18 74241 132.48 125.86 144.74 74415 155.00 147.25 169.34
C 73706 TC 425.91 404.61 465.30
C 73718 496.18 471.37 542.08
7424126 37.82 35.93 41.32
74241 TC 94.66 89.93 103.42
7441526 26.93 25.58 29.42
74415TC 128.07 121.67 139.92
7371826 74.08 70.38 80.94
C 73718 TC 422.10 401.00 461.15
74245 199.47 189.50 217.93
7424526 50.35 47.83 55.00
74420 142.71 135.57 155.91
7442026 20.28 19.27 22.16
C 73719 606.70 576.37 662.83
7371926 88.92 84.47 97.14
74245 TC 149.13 141.67 162.92
74246 142.78 135.64 155.99
74420 TC 122.21 116.10 133.52
74425 81.39 77.32 88.92
C 73719 TC 517.78 491.89 565.67 7424626 38.26 36.35 41.80 7442526 20.28 19.27 22.16
C 73720 769.34 730.87 840.50
7372026 118.53 112.60 129.49
74246 TC 104.52 99.29 114.18
C 74247 144.55 137.32 157.92
74425 TC 60.88 57.84 66.52
74430 91.65 87.07 100.13
C 73720 TC 650.81 618.27 711.01
C 73721 496.02 471.22 541.90
7424726 38.26 36.35 41.80
C 74247 TC 106.28 100.97 116.12
7443026 17.90 17.01 19.56
74430TC 73.76 70.07 80.58
7372126 74.08 70.38 80.94 74249 214.34 203.62 234.16 74440 98.32 93.40 107.41
C 73721 TC 421.95 400.85 460.98
C 73722 606.99 576.64 663.14
7424926 50.35 47.83 55.00
74249 TC 164.00 155.80 179.17
7444026 21.03 19.98 22.98
74440TC 77.29 73.43 84.44
7372226 89.36 84.89 97.62
C 73722 TC 517.63 491.75 565.51
74250 117.90 112.01 128.81
7425026 25.74 24.45 28.12
74445 117.25 111.39 128.10
7444526 64.71 61.47 70.69
C 73723 768.44 730.02 839.52
7372326 118.53 112.60 129.49
74250 TC 92.16 87.55 100.68
C 74251 212.62 201.99 232.29
74445TC 52.50 49.88 57.36
74450 86.79 82.45 94.82
C 73723 TC 649.91 617.41 710.02 7425126 38.26 36.35 41.80 7445026 18.71 17.77 20.44
C 73725 617.10 586.25 674.19
7372526 100.70 95.67 110.02
C 74251 TC 174.35 165.63 190.47
C 74260 134.65 127.92 147.11
74450 TC 67.92 64.52 74.20
74455 106.44 101.12 116.29
C 73725 TC 516.40 490.58 564.17
74000 29.28 27.82 31.99
7426026 27.31 25.94 29.83
C 74260 TC 107.35 101.98 117.28
7445526 18.71 17.77 20.44
74455TC 87.73 83.34 95.84
7400026 9.70 9.22 10.60 C 74270 144.70 137.47 158.09 74470 88.61 84.18 96.81
74000 TC 19.58 18.60 21.39
74010 43.22 41.06 47.22
7427026 38.26 36.35 41.80
C 74270 TC 106.44 101.12 116.29
7447026 30.13 28.62 32.91
74470TC 58.21 55.30 63.60
7401026 12.46 11.84 13.62
74010 TC 30.76 29.22 33.60
C 74280 227.66 216.28 248.72
7428026 54.68 51.95 59.74
74475 144.76 137.52 158.15
7447526 30.13 28.62 32.91
74020 46.05 43.75 50.31
7402026 14.85 14.11 16.23
C 74280 TC 172.99 164.34 188.99
C 74283 217.13 206.27 237.21
74475TC 114.62 108.89 125.22
74480 145.20 137.94 158.63
74020 TC 31.20 29.64 34.09 7428326 111.15 105.59 121.43 7448026 30.13 28.62 32.91
74022 55.73 52.94 60.88
7402226 17.61 16.73 19.24
C 74283 TC 105.98 100.68 115.78
74290 75.17 71.41 82.12
74480TC 115.07 109.32 125.72
74485 138.30 131.39 151.10
74022 TC 38.12 36.21 41.64
C 74150 299.61 284.63 327.32
7429026 17.61 16.73 19.24
74290 TC 57.56 54.68 62.88
7448526 30.42 28.90 33.24
74485TC 107.87 102.48 117.85
7415026 65.57 62.29 71.63 74291 65.37 62.10 71.42 74710 49.99 47.49 54.61
C 74150 TC 234.04 222.34 255.69
74160 430.55 409.02 470.37
7429126 10.89 10.35 11.90
74291 TC 54.48 51.76 59.52
7471026 19.09 18.14 20.86
74710TC 30.90 29.36 33.76
7416026 70.63 67.10 77.17
74160 TC 359.92 341.92 393.21
7430026 19.84 18.85 21.68
7430126 11.71 11.12 12.79
74740 90.66 86.13 99.05
7474026 21.03 19.98 22.98
C 74170 489.33 464.86 534.59
7417026 77.28 73.42 84.43
74305 60.37 57.35 65.95
7430526 23.42 22.25 25.59
74740TC 69.63 66.15 76.07
74742 179.95 170.95 196.59
C 74170 TC 412.05 391.45 450.17 74305 TC 36.56 34.73 39.94 7474226 33.49 31.82 36.59
C 74175 531.82 505.23 581.01
7417526 105.47 100.20 115.23
74320 133.59 126.91 145.95
7432026 30.13 28.62 32.91
74742TC 145.37 138.10 158.82
74775 103.23 98.07 112.78
CODES: 73600 - 74775
# - These amounts apply when the service is performed in a facility setting.
C - The payment for the technical component is capped at the OPPS amount.
Limiting charge applies to unassigned claims by non-participating providers. All CPT codes and modifiers are bolded.
All Current Procedural Terminology (CPT) codes and descriptors are copyrighted 2008 by the American Medical Association..

7477526
74775TC
75557
7555726
75557TC
75559
7555926
75559TC
75561
7556126
75561TC
75563
7556326
75563TC
75600
7560026
75600TC
75605
7560526
75605TC
75625
7562526
75625TC
75630
7563026
75630TC
75635
7563526
75635TC
75650
7565026
75650TC
75658
7565826
75658TC
75660
7566026
75660TC
75662
7566226
75662TC
75665
7566526
75665TC
75671
7567126
75671TC
75676
7567626
75676TC
75680
7568026
75680TC
75685
7568526
75685TC
75705
7570526
75705TC
75710
7571026
75710TC
75716
7571626
75716TC
75722
7572226
75722TC
75724
7572426
75724TC
75726
7572626
75726TC
75731
7573126
75731TC
75733
7573326
75733TC
75736
7573626
75736TC
75741
7574126
75741TC
75743
7574326
75743TC
75746
7574626
75746TC
75756
7575626
75756TC
75774
7577426
75774TC
75790
7579026
75790TC
75801
7580126
75801TC
75803
7580326
75803TC
75805
7580526
75805TC
75807
7580726
75807TC
75809
7580926
75809TC
75810
7581026
75810TC
75820
7582026
75820TC
75822
7582226
75822TC
75825
7582526
75825TC
75827
7582726
75827TC
75831
7583126
75831TC
75833
7583326
75833TC
75840
7584026
75840TC
75842
7584226
75842TC
75860
7586026
75860TC
75870
7587026
75870TC
75872
7587226
75872TC
75880
7588026
75880TC
75885
7588526
75885TC
75887
7588726
75887TC
75889
7588926
75889TC
75891
7589126
75891TC
75893
7589326
75893TC
75894
7589426
75894TC
75896
7589626
75896TC
75898
7589826
75898TC
75900
7590026
75900TC
75901
7590126
75901TC
75902
7590226
75902TC
75940
7594026
75940TC
75945
7594526
75945TC
75946
7594626
75946TC
7595226
7595326
7595426
7595626
7595726
7595826
7595926
75960
7596026
75960TC
75961
7596126
75961TC
75962
7596226
75962TC
75964
7596426
75964TC
75966
7596626
75966TC
75968
7596826
75968TC
75970
7597026
75970TC
75978
7597826
75978TC
75980
7598026
75980TC






California - MEDICARE CARRIER 01192 FSY2009 LOCALITY 18 FEE SCHEDULE PAGE: 35
PROCEDURE PAR NONPAR LIMITING
CODE/MOD FEE FEE CHARGE
PROCEDURE PAR NONPAR LIMITING
CODE/MOD FEE FEE CHARGE
PROCEDURE PAR NONPAR LIMITING
CODE/MOD FEE FEE CHARGE
7477526 34.31 32.59 37.48
74775 TC 67.92 64.52 74.20
75733 389.21 369.75 425.21
7573326 78.76 74.82 86.04
75880TC 102.47 97.35 111.95
75885 326.93 310.58 357.17
C 75557 549.97 522.47 600.84 75733 TC 310.45 294.93 339.17 7588526 80.55 76.52 88.00
7555726 135.31 128.54 147.82
C 75557 TC 414.66 393.93 453.02
75736 334.66 317.93 365.62
7573626 64.42 61.20 70.38
75885TC 246.38 234.06 269.17
75887 329.58 313.10 360.07
C 75559 591.91 562.31 646.66
7555926 173.30 164.64 189.34
75736 TC 270.24 256.73 295.24
75741 319.84 303.85 349.43
7588726 80.55 76.52 88.00
75887TC 249.03 236.58 272.07
C 75559 TC 418.61 397.68 457.33 7574126 73.46 69.79 80.26 75889 309.63 294.15 338.27
C 75561 795.36 755.59 868.93
7556126 149.41 141.94 163.23
75741 TC 246.38 234.06 269.17
75743 348.73 331.29 380.98
7588926 63.69 60.51 69.59
75889TC 245.94 233.64 268.69
C 75561 TC 645.95 613.65 705.70
C 75563 827.98 786.58 904.57
7574326 93.51 88.83 102.15
75743 TC 255.22 242.46 278.83
75891 309.63 294.15 338.27
7589126 63.69 60.51 69.59
7556326 179.45 170.48 196.05
C 75563 TC 648.53 616.10 708.52
75746 324.21 308.00 354.20
7574626 63.25 60.09 69.10
75891TC 245.94 233.64 268.69
75893 275.19 261.43 300.64
75600 382.00 362.90 417.34 75746 TC 260.96 247.91 285.10 7589326 29.69 28.21 32.44
7560026 29.14 27.68 31.83
75600 TC 352.86 335.22 385.50
75756 344.69 327.46 376.58
7575626 68.26 64.85 74.58
75893TC 245.50 233.23 268.21
75894 1,198.46 1,138.54 1,309.32
75605 321.12 305.06 350.82
7560526 65.46 62.19 71.52
75756 TC 276.43 262.61 302.00
75774 255.18 242.42 278.78
7589426 73.15 69.49 79.91
75894 TC 1,123.87 1,067.68 1,227.83
75605 TC 255.66 242.88 279.31 7577426 20.28 19.27 22.16 75896 1,051.78 999.19 1,149.07
75625 316.55 300.72 345.83
7562526 63.54 60.36 69.41
75774 TC 234.90 223.16 256.63
75790 199.05 189.10 217.47
7589626 73.61 69.93 80.42
75896TC 977.40 928.53 1,067.81
75625 TC 253.01 240.36 276.41
75630 364.33 346.11 398.03
7579026 99.53 94.55 108.73
75790 TC 99.52 94.54 108.72
75898 142.14 135.03 155.28
7589826 92.70 88.07 101.28
7563026 101.76 96.67 111.17
75630 TC 262.57 249.44 286.86
75801 299.79 284.80 327.52
7580126 43.78 41.59 47.83
75898TC 48.94 46.49 53.46
75900 994.90 945.16 1,086.93
C 75635 562.08 533.98 614.08 75801 TC 252.36 239.74 275.70 7590026 27.22 25.86 29.74
7563526 135.27 128.51 147.79
C 75635 TC 426.81 405.47 466.29
75803 318.00 302.10 347.42
7580326 65.26 62.00 71.30
75900TC 966.94 918.59 1,056.38
75901 196.80 186.96 215.00
75650 337.93 321.03 369.18
7565026 83.60 79.42 91.33
75803 TC 252.36 239.74 275.70
75805 330.87 314.33 361.48
7590126 26.93 25.58 29.42
75901TC 169.87 161.38 185.59
75650 TC 254.34 241.62 277.86 7580526 45.56 43.28 49.77 75902 109.10 103.65 119.20
75658 335.15 318.39 366.15
7565826 71.54 67.96 78.15
75805 TC 284.55 270.32 310.87
75807 347.42 330.05 379.56
7590226 21.41 20.34 23.39
75902TC 87.69 83.31 95.81
75658 TC 263.61 250.43 287.99
75660 341.49 324.42 373.08
7580726 65.26 62.00 71.30
75807 TC 281.54 267.46 307.58
75940 617.65 586.77 674.79
7594026 29.83 28.34 32.59
7566026 73.46 69.79 80.26
75660 TC 268.03 254.63 292.82
75809 101.41 96.34 110.79
7580926 25.74 24.45 28.12
75940TC 586.52 557.19 640.77
C 75945 205.41 195.14 224.41
75662 391.30 371.74 427.50 75809 TC 75.67 71.89 82.67 7594526 22.81 21.67 24.92
7566226 94.55 89.82 103.29
75662 TC 296.75 281.91 324.20
75810 650.52 617.99 710.69
7581026 64.13 60.92 70.06
C 75945TC 182.61 173.48 199.50
75946 130.10 123.60 142.14
75665 350.75 333.21 383.19
7566526 73.88 70.19 80.72
75810 TC 586.52 557.19 640.77
75820 138.90 131.96 151.75
7594626 22.21 21.10 24.27
75946TC 105.91 100.61 115.70
75665 TC 276.87 263.03 302.48 7582026 39.52 37.54 43.17 7595226 243.79 231.60 266.34
75671 396.45 376.63 433.12
7567126 93.07 88.42 101.68
75820 TC 99.38 94.41 108.57
75822 168.60 160.17 184.20
7595326 73.83 70.14 80.66
7595426 120.20 114.19 131.32
75671 TC 303.38 288.21 331.44
75676 341.78 324.69 373.39
7582226 58.48 55.56 63.89
75822 TC 110.12 104.61 120.30
7595626 382.23 363.12 417.59
7595726 327.21 310.85 357.48
7567626 73.31 69.64 80.09
75676 TC 268.47 255.05 293.31
75825 304.91 289.66 333.11
7582526 62.95 59.80 68.77
7595826 215.83 205.04 235.80
7595926 189.87 180.38 207.44
75680 380.10 361.10 415.27 75825 TC 241.97 229.87 264.35 75960 310.38 294.86 339.09
7568026 93.51 88.83 102.15
75680 TC 286.59 272.26 313.10
75827 304.33 289.11 332.48
7582726 61.48 58.41 67.17
7596026 46.38 44.06 50.67
75960TC 264.00 250.80 288.42
75685 342.37 325.25 374.04
7568526 73.46 69.79 80.26
75827 TC 242.85 230.71 265.32
75831 308.60 293.17 337.15
75961 470.63 447.10 514.17
7596126 234.66 222.93 256.37
75685 TC 268.92 255.47 293.79 7583126 63.10 59.95 68.94 75961TC 235.97 224.17 257.80
75705 389.88 370.39 425.95
7570526 122.73 116.59 134.08
75831 TC 245.50 233.23 268.21
75833 342.93 325.78 374.65
75962 334.16 317.45 365.07
7596226 29.98 28.48 32.75
75705 TC 267.15 253.79 291.86
75710 335.40 318.63 366.42
7583326 81.53 77.45 89.07
75833 TC 261.41 248.34 285.59
75962TC 304.18 288.97 332.32
75964 196.95 187.10 215.17
7571026 63.83 60.64 69.74
75710 TC 271.57 257.99 296.69
75840 305.79 290.50 334.08
7584026 62.06 58.96 67.80
7596426 20.13 19.12 21.99
75964TC 176.82 167.98 193.18
75716 374.03 355.33 408.63 75840 TC 243.73 231.54 266.27 75966 387.80 368.41 423.67
7571626 73.31 69.64 80.09
75716 TC 300.73 285.69 328.54
75842 345.00 327.75 376.91
7584226 82.71 78.57 90.36
7596626 75.22 71.46 82.18
75966TC 312.57 296.94 341.48
75722 331.28 314.72 361.93
7572226 65.02 61.77 71.04
75842 TC 262.29 249.18 286.56
75860 315.09 299.34 344.24
75968 197.55 187.67 215.82
7596826 20.72 19.68 22.63
75722 TC 266.27 252.96 290.90 7586026 64.73 61.49 70.71 75968TC 176.82 167.98 193.18
75724 385.07 365.82 420.69
7572426 88.76 84.32 96.97
75860 TC 250.36 237.84 273.52
75870 312.28 296.67 341.17
75970 584.27 555.06 638.32
7597026 46.46 44.14 50.76
75724 TC 296.31 281.49 323.71
75726 331.72 315.13 362.40
7587026 62.81 59.67 68.62
75870 TC 249.48 237.01 272.56
75970TC 537.05 510.20 586.73
75978 328.57 312.14 358.96
7572626 63.69 60.51 69.59
75726 TC 268.03 254.63 292.82
75872 341.40 324.33 372.98
7587226 66.74 63.40 72.91
7597826 29.25 27.79 31.96
75978TC 299.32 284.35 327.00
75731 343.50 326.33 375.28 75872 TC 274.66 260.93 300.07 75980 333.21 316.55 364.03
7573126 67.52 64.14 73.76
75731 TC 275.99 262.19 301.52
75880 140.23 133.22 153.20
7588026 37.76 35.87 41.25
7598026 80.11 76.10 87.52
75980TC 252.36 239.74 275.70
CODES: 7477526 - 75980TC
# - These amounts apply when the service is performed in a facility setting.
C - The payment for the technical component is capped at the OPPS amount.
Limiting charge applies to unassigned claims by non-participating providers. All CPT codes and modifiers are bolded.
All Current Procedural Terminology (CPT) codes and descriptors are copyrighted 2008 by the American Medical Association.

75982
7598226
75982TC
75984
7598426
75984TC
75989
7598926
75989TC
75992
7599226
75992TC
75993
7599326
75993TC
75994
7599426
75994TC
75995
7599526
75995TC
75996
7599626
75996TC
76000
7600026
76000TC
76001
7600126
76001TC
76010
7601026
76010TC
76080
7608026
76080TC
76098
7609826
76098TC
76100
7610026
76100TC
76101
7610126
76101TC
76102
7610226
76102TC
76120
7612026
76120TC
76125
7612526
76125TC
76150
76350
76376
7637626
76376TC
76377
7637726
76377TC
76380
7638026
76380TC
76506
7650626
76506TC
76510
7651026
76510TC
76511
7651126
76511TC
76512
7651226
76512TC
76513
7651326
76513TC
76514
7651426
76514TC
76516
7651626
76516TC
76519
7651926
76519TC
76529
7652926
76529TC
76536
7653626
76536TC
76604
7660426
76604TC
76645
7664526
76645TC
76700
7670026
76700TC
76705
7670526
76705TC
76770
7677026
76770TC
76775
76775
7677526
7677526
76775TC
76776
7677626
76776TC
76800
7680026
76800TC
76801
7680126
76801TC
76802
7680226
76802TC
76805
7680526
76805TC
76810
7681026
76810TC
76811
7681126
76811TC
76812
7681226
76812TC
76813
7681326
76813TC
76814
7681426
76814TC
76815
7681526
76815TC
76816
7681626
76816TC
76817
7681726
76817TC
76818
7681826
76818TC
76819
7681926
76819TC
76820
7682026
76820TC
76821
7682126
76821TC
76825
7682526
76825TC
76826
7682626
76826TC
76827
7682726
76827TC
76828
7682826
76828TC
76830
7683026
76830TC
76831
7683126
76831TC
76856
7685626
76856TC
76857
7685726
76857TC
76870
7687026
76870TC
76872
7687226
76872TC
76873
7687326
76873TC
76880
7688026
76880TC
76885
7688526
76885TC
76886
7688626
76886TC
76930
7693026
76930TC
76932
7693226
76932TC
76936
7693626
76936TC
76937
7693726
76937TC
76940
7694026
76940TC
76941
7694126
76941TC
76942
7694226
76942TC
76945
7694526






California - MEDICARE CARRIER 01192 FSY2009 LOCALITY 18 FEE SCHEDULE PAGE: 36
PROCEDURE PAR NONPAR CHARGE
CODE/MOD FEE FEE LIMIT
PROCEDURE PAR NONPAR CHARGE
CODE/MOD FEE FEE LIMIT
PROCEDURE PAR NONPAR CHARGE
CODE/MOD FEE FEE LIMIT
75982 362.66 344.53 396.21
7598226 80.11 76.10 87.52
76513 96.30 91.49 105.21
7651326 35.96 34.16 39.28
76818 138.32 131.40 151.11
7681826 55.89 53.10 61.07
75982 TC 281.54 267.46 307.58 76513 TC 60.34 57.32 65.92 76818 TC 82.43 78.31 90.06
75984 132.71 126.07 144.98
7598426 40.27 38.26 44.00
76514 14.03 13.33 15.33
7651426 9.77 9.28 10.67
76819 107.35 101.98 117.28
7681926 41.27 39.21 45.09
75984 TC 92.44 87.82 100.99
75989 165.49 157.22 180.80
76514 TC 4.27 4.06 4.67
76516 76.94 73.09 84.05
76819TC 66.08 62.78 72.20
76820 61.56 58.48 67.25
7598926 66.01 62.71 72.12 7651626 29.84 28.35 32.60 7682026 26.71 25.37 29.18
75989 TC 99.48 94.51 108.69
75992 764.55 726.32 835.27
76516 TC 47.10 44.75 51.46
76519 82.68 78.55 90.33
76820TC 34.85 33.11 38.08
76821 112.37 106.75 122.76
7599226 30.86 29.32 33.72
75992 TC 733.35 696.68 801.18
7651926 30.28 28.77 33.09
76519 TC 52.40 49.78 57.25
7682126 37.31 35.44 40.76
76821 TC 75.05 71.30 82.00
75993 407.36 386.99 445.04
7599326 20.28 19.27 22.16
76529 77.76 73.87 84.95
7652926 31.70 30.12 34.64
76825 239.79 227.80 261.97
7682526 89.03 84.58 97.27
75993 TC 386.35 367.03 422.08 76529 TC 46.06 43.76 50.32 76825TC 150.76 143.22 164.70
75994 801.47 761.40 875.61
7599426 67.12 63.76 73.32
76536 129.08 122.63 141.02
7653626 30.00 28.50 32.78
76826 132.89 126.25 145.19
7682626 43.52 41.34 47.54
75994 TC 725.67 689.39 792.80
75995 801.18 761.12 875.29
76536 TC 99.08 94.13 108.25
76604 100.14 95.13 109.40
76826 TC 89.37 84.90 97.64
76827 82.39 78.27 90.01
7599526 71.84 68.25 78.49 7660426 30.07 28.57 32.86 7682726 30.75 29.21 33.59
75995 TC 725.67 689.39 792.80
75996 406.93 386.58 444.57
76604 TC 70.07 66.57 76.56
C 76645 105.21 99.95 114.94
76827TC 51.64 49.06 56.42
76828 60.00 57.00 65.55
7599626 19.84 18.85 21.68
75996 TC 386.35 367.03 422.08
7664526 29.69 28.21 32.44
C 76645 TC 75.52 71.74 82.50
7682826 29.85 28.36 32.61
76828TC 30.15 28.64 32.94
C 76000 110.32 104.80 120.52
7600026 9.32 8.85 10.18
76700 158.91 150.96 173.60
7670026 44.38 42.16 48.48
76830 139.69 132.71 152.62
7683026 37.38 35.51 40.84
C 76000 TC 101.00 95.95 110.34 76700 TC 114.53 108.80 125.12 76830TC 102.31 97.19 111.77
76001 160.70 152.67 175.57
7600126 37.65 35.77 41.14
76705 120.77 114.73 131.94
7670526 32.74 31.10 35.77
76831 139.49 132.52 152.40
7683126 38.06 36.16 41.58
76001 TC 122.21 116.10 133.52
76010 32.37 30.75 35.36
76705 TC 88.03 83.63 96.17
76770 152.46 144.84 166.57
76831TC 101.42 96.35 110.80
76856 140.57 133.54 153.57
7601026 10.14 9.63 11.07 7677026 40.58 38.55 44.33 7685626 37.82 35.93 41.32
76010 TC 22.23 21.12 24.29
76080 72.96 69.31 79.71
76770 TC 111.88 106.29 122.23
76775 130.56 124.03 142.63
76856 TC 102.75 97.61 112.25
C 76857 97.59 92.71 106.62
7608026 30.13 28.62 32.91
76080 TC 42.83 40.69 46.79
# 76775 130.12 123.61 142.15
7677526 32.81 31.17 35.85
7685726 21.47 20.40 23.46
C 76857TC 76.12 72.31 83.16
76098 22.78 21.64 24.89
7609826 8.95 8.50 9.78
# 7677526 32.37 30.75 35.36
76775 TC 97.75 92.86 106.79
76870 139.58 132.60 152.49
7687026 35.50 33.73 38.79
76098 TC 13.83 13.14 15.11 76776 170.00 161.50 185.73 76870 TC 104.08 98.88 113.71
C 76100 122.18 116.07 133.48
7610026 31.92 30.32 34.87
7677626 41.78 39.69 45.64
76776 TC 128.22 121.81 140.08
C 76872 157.80 149.91 172.40
7687226 39.44 37.47 43.09
C 76100 TC 90.25 85.74 98.60
76101 219.81 208.82 240.14
76800 140.30 133.29 153.28
7680026 58.01 55.11 63.38
C 76872 TC 118.37 112.45 129.32
C 76873 202.85 192.71 221.62
7610126 31.48 29.91 34.40 76800 TC 82.29 78.18 89.91 7687326 85.55 81.27 93.46
76101 TC 188.32 178.90 205.74
C 76102 273.85 260.16 299.18
76801 150.94 143.39 164.90
7680126 53.79 51.10 58.77
C 76873TC 117.30 111.44 128.16
76880 146.84 139.50 160.43
7610226 31.04 29.49 33.91
C 76102 TC 242.81 230.67 265.27
76801 TC 97.14 92.28 106.12
76802 83.08 78.93 90.77
7688026 31.42 29.85 34.33
76880TC 115.42 109.65 126.10
76120 88.16 83.75 96.31
7612026 20.59 19.56 22.49
7680226 44.69 42.46 48.83
76802 TC 38.38 36.46 41.93
C 76885 116.11 110.30 126.85
7688526 40.58 38.55 44.33
76120 TC 67.57 64.19 73.82 76805 169.05 160.60 184.69 C 76885TC 75.52 71.74 82.50
76125 51.75 49.16 56.53
7612526 15.73 14.94 17.18
7680526 53.35 50.68 58.28
76805 TC 115.70 109.92 126.41
C 76886 108.80 103.36 118.86
7688626 33.43 31.76 36.52
76125 TC 36.56 34.73 39.94
76150 22.23 21.12 24.29
76810 114.14 108.43 124.69
7681026 52.53 49.90 57.39
C 76886TC 75.37 71.60 82.34
76930 113.91 108.21 124.44
76350 16.19 15.38 17.69 76810 TC 61.61 58.53 67.31 7693026 39.87 37.88 43.56
76376 95.24 90.48 104.05
7637626 11.62 11.04 12.70
76811 233.54 221.86 255.14
7681126 100.90 95.86 110.24
76930 TC 74.03 70.33 80.88
76932 110.05 104.55 120.23
76376 TC 83.61 79.43 91.34
76377 128.45 122.03 140.33
76811 TC 132.64 126.01 144.91
C 76812 167.43 159.06 182.92
7693226 39.87 37.88 43.56
76932TC 71.34 67.77 77.94
7637726 44.79 42.55 48.93
76377 TC 83.66 79.48 91.40
7681226 94.33 89.61 103.05
C 76812 TC 73.09 69.44 79.86
C 76936 224.22 213.01 244.96
7693626 110.74 105.20 120.98
C 76380 180.61 171.58 197.32 76813 145.69 138.41 159.17 C 76936TC 113.48 107.81 123.98
7638026 53.86 51.17 58.85
C 76380 TC 126.75 120.41 138.47
7681326 61.66 58.58 67.37
76813 TC 84.03 79.83 91.80
76937 41.10 39.05 44.91
7693726 16.99 16.14 18.56
C 76506 111.08 105.53 121.36
7650626 35.56 33.78 38.85
76814 93.05 88.40 101.66
7681426 51.87 49.28 56.67
76937TC 24.11 22.90 26.34
76940 198.80 188.86 217.19
C 76506 TC 75.52 71.74 82.50 76814 TC 41.17 39.11 44.98 7694026 114.57 108.84 125.17
76510 168.46 160.04 184.05
7651026 86.90 82.56 94.94
76815 104.91 99.66 114.61
7681526 34.99 33.24 38.23
76940TC 78.32 74.40 85.56
76941 148.25 140.84 161.97
76510 TC 81.56 77.48 89.10
76511 110.21 104.70 120.41
76815 TC 69.92 66.42 76.38
C 76816 121.12 115.06 132.32
7694126 71.78 68.19 78.42
76941TC 71.04 67.49 77.61
7651126 52.51 49.88 57.36
76511 TC 57.70 54.82 63.04
7681626 45.44 43.17 49.65
C 76816 TC 75.67 71.89 82.67
76942 218.91 207.96 239.15
7694226 37.07 35.22 40.50
76512 102.84 97.70 112.36 C 76817 115.60 109.82 126.29 76942TC 181.84 172.75 198.66
7651226 52.66 50.03 57.53
76512 TC 50.17 47.66 54.81
7681726 40.07 38.07 43.78
C 76817 TC 75.52 71.74 82.50
76945 108.80 103.36 118.86
7694526 35.75 33.96 39.05
CODES: 75982 - 7694526
# - These amounts apply when the service is performed in a facility setting.
C - The payment for the technical component is capped at the OPPS amount.
Limiting charge applies to unassigned claims by non-participating providers. All CPT codes and modifiers are bolded.
All Current Procedural Terminology (CPT) codes and descriptors are copyrighted 2008 by the American Medical Association..

76945TC
76946
7694626
76946TC
76948
7694826
76948TC
76950
7695026
76950TC
76965
7696526
76965TC
76970
7697026
76970TC
76975
7697526
76975TC
76977
7697726
76977TC
76998
7699826
76998TC
77001
7700126
77001TC
77002
7700226
77002TC
77003
7700326
77003TC
77011
7701126
77011TC
77012
7701226
77012TC
77013
7701326
77013TC
77014
7701426
77014TC
77021
7702126
77021TC
77022
7702226
77022TC
77031
7703126
77031TC
77032
7703226
77032TC
77051
7705126
77051TC
77052
7705226
77052TC
77053
7705326
77053TC
77054
7705426
77054TC
77055
7705526
77055TC
77056
7705626
77056TC
77057
7705726
77057TC
77058
7705826
77058TC
77059
7705926
77059TC
77071
77072
7707226
77072TC
77073
7707326
77073TC
77074
7707426
77074TC
77075
7707526
77075TC
77076
7707626
77076TC
77077
7707726
77077TC
77078
7707826
77078TC
77079
7707926
77079TC
77080
7708026
77080TC
77081
7708126
77081TC
77082
7708226
77082TC
77083
7708326
77083TC
77084
7708426
77084TC
77261
77262
77263
77280
7728026
77280TC
77285
7728526
77285TC
77290
7729026
77290TC
77295
7729526
77295TC
77300
7730026
77300TC
77301
7730126
77301TC
77305
7730526
77305TC
77310
7731026
77310TC
77315
7731526
77315TC
77321
7732126
77321TC
77326
7732626
77326TC
77327
7732726
77327TC
77328
7732826
77328TC
77331
7733126
77331TC
77332
7733226
77332TC
77333
7733326
77333TC
77334
7733426
77334TC
77336
77370
77372
77373
77401
77402
77403
77404
77406
77407
77408
77409
77411
77412
77413
77414
77416
77417
77418
77421
7742126
77421TC
77422
77423
77427
77431
77432
77435
77470
7747026
77470TC
77520
77600
7760026
77600TC
77605
7760526
77605TC
77610
7761026
77610TC
77615
7761526
77615TC
77620
7762026
77620TC
77750
7775026
77750TC
77761
7776126






California - MEDICARE CARRIER 01192 FSY2009 LOCALITY 18 FEE SCHEDULE PAGE: 37
PROCEDURE PAR NONPAR LIMITING
CODE/MOD FEE FEE CHARGE
PROCEDURE PAR NONPAR LIMITING
CODE/MOD FEE FEE CHARGE
PROCEDURE PAR NONPAR LIMITING
CODE/MOD FEE FEE CHARGE
76945 TC 71.04 67.49 77.61
76946 50.88 48.34 55.59
7705726 38.64 36.71 42.22
77057 TC 55.05 52.30 60.15
77315TC 84.47 80.25 92.29
77321 140.85 133.81 153.88
7694626 20.15 19.14 22.01 77058 1,003.14 952.98 1,095.93 7732126 51.26 48.70 56.01
76946 TC 30.73 29.19 33.57
76948 50.88 48.34 55.59
7705826 89.74 85.25 98.04
77058 TC 913.40 867.73 997.89
77321TC 89.59 85.11 97.88
77326 166.05 157.75 181.41
7694826 20.15 19.14 22.01
76948 TC 30.73 29.19 33.57
77059 1,077.81 1,023.92 1,177.51
7705926 89.74 85.25 98.04
7732626 50.06 47.56 54.69
77326TC 115.99 110.19 126.72
76950 81.23 77.17 88.75 77059 TC 988.07 938.67 1,079.47 77327 236.16 224.35 258.00
7695026 31.48 29.91 34.40
76950 TC 49.75 47.26 54.35
77071 44.53 42.30 48.65
77072 27.00 25.65 29.50
7732726 74.98 71.23 81.91
77327TC 161.18 153.12 176.09
76965 167.96 159.56 183.49
7696526 75.16 71.40 82.11
7707226 10.52 9.99 11.49
77072 TC 16.49 15.67 18.02
77328 322.19 306.08 351.99
7732826 113.03 107.38 123.49
76965 TC 92.80 88.16 101.38
C 76970 96.42 91.60 105.34
77073 43.25 41.09 47.25
7707326 14.85 14.11 16.23
77328TC 209.16 198.70 228.51
77331 69.75 66.26 76.20
7697026 20.90 19.86 22.84 77073 TC 28.40 26.98 31.03 7733126 47.08 44.73 51.44
C 76970 TC 75.52 71.74 82.50
76975 117.73 111.84 128.62
77074 79.74 75.75 87.11
7707426 24.99 23.74 27.30
77331TC 22.67 21.54 24.77
77332 90.33 85.81 98.68
7697526 45.27 43.01 49.46
76975 TC 71.34 67.77 77.94
77074 TC 54.76 52.02 59.82
77075 116.40 110.58 127.17
7733226 29.10 27.65 31.80
77332TC 61.23 58.17 66.90
76977 16.43 15.61 17.95 7707526 29.69 28.21 32.44 77333 77.42 73.55 84.58
7697726 3.05 2.90 3.34
76977 TC 13.38 12.71 14.62
77075 TC 86.71 82.37 94.73
77076 107.24 101.88 117.16
7733326 45.51 43.23 49.71
77333TC 31.91 30.31 34.86
76998 192.90 183.26 210.75
7699826 66.05 62.75 72.16
7707626 36.87 35.03 40.28
77076 TC 70.37 66.85 76.88
77334 182.68 173.55 199.58
7733426 66.85 63.51 73.04
76998 TC 122.21 116.10 133.52
77001 123.05 116.90 134.44
77077 48.86 46.42 53.38
7707726 17.08 16.23 18.66
77334TC 115.83 110.04 126.55
77336 74.45 70.73 81.34
7700126 20.74 19.70 22.66 77077 TC 31.78 30.19 34.72 77370 141.74 134.65 154.85
77001 TC 102.31 97.19 111.77
77002 81.65 77.57 89.21
C 77078 100.51 95.48 109.80
7707826 13.65 12.97 14.92
77372 989.02 939.57 1,080.51
77373 1,832.00 1,740.40 2,001.46
7700226 28.81 27.37 31.48
77002 TC 52.84 50.20 57.73
C 77078 TC 86.86 82.52 94.90
77079 67.88 64.49 74.16
77401 38.09 36.19 41.62
77402 164.45 156.23 179.66
77003 66.96 63.61 73.15 7707926 11.20 10.64 12.24 77403 144.57 137.34 157.94
7700326 30.02 28.52 32.80
77003 TC 36.93 35.08 40.34
77079 TC 56.68 53.85 61.93
77080 83.86 79.67 91.62
77404 159.15 151.19 173.87
77406 160.48 152.46 175.33
77011 811.47 770.90 886.54
7701126 65.88 62.59 71.98
7708026 10.89 10.35 11.90
77080 TC 72.97 69.32 79.72
77407 257.97 245.07 281.83
77408 193.90 184.21 211.84
77011 TC 745.59 708.31 814.56
77012 230.82 219.28 252.17
77081 34.74 33.00 37.95
7708126 11.64 11.06 12.72
77409 213.78 203.09 233.55
77411 212.46 201.84 232.12
7701226 64.44 61.22 70.40 77081 TC 23.10 21.95 25.24 77412 249.86 237.37 272.98
77012 TC 166.37 158.05 181.76
77013 646.62 614.29 706.43
77082 33.75 32.06 36.87
7708226 8.88 8.44 9.71
77413 251.63 239.05 274.91
77414 279.46 265.49 305.31
7701326 222.18 211.07 242.73
77013 TC 422.20 401.09 461.25
77082 TC 24.87 23.63 27.17
77083 30.46 28.94 33.28
77416 280.79 266.75 306.76
77417 19.27 18.31 21.06
77014 217.97 207.07 238.13 7708326 10.45 9.93 11.42 77418 631.15 599.59 689.53
7701426 45.89 43.60 50.14
77014 TC 172.09 163.49 188.01
77083 TC 20.01 19.01 21.86
C 77084 508.74 483.30 555.80
77421 134.32 127.60 146.74
7742126 20.97 19.92 22.91
77021 529.06 502.61 578.00
7702126 83.67 79.49 91.41
7708426 88.61 84.18 96.81
C 77084 TC 420.13 399.12 458.99
77421TC 113.35 107.68 123.83
77422 235.28 223.52 257.05
77021 TC 445.39 423.12 486.59
77022 797.76 757.87 871.55
77261 76.75 72.91 83.85
77262 115.10 109.35 125.75
77423 270.18 256.67 295.17
77427 203.49 193.32 222.32
7702226 231.98 220.38 253.44 77263 170.69 162.16 186.48 77431 104.59 99.36 114.26
77022 TC 557.55 529.67 609.12
77031 221.04 209.99 241.49
77280 217.78 206.89 237.92
7728026 38.05 36.15 41.57
77432 432.07 410.47 472.04
77435 717.82 681.93 784.22
7703126 87.49 83.12 95.59
77031 TC 133.55 126.87 145.90
77280 TC 179.74 170.75 196.36
77285 376.52 357.69 411.34
77470 293.61 278.93 320.77
7747026 113.03 107.38 123.49
77032 68.26 64.85 74.58 7728526 56.78 53.94 62.03 77470TC 180.58 171.55 197.28
7703226 30.88 29.34 33.74
77032 TC 37.38 35.51 40.84
77285 TC 319.74 303.75 349.31
77290 585.31 556.04 639.45
77520 962.21 914.10 1,051.22
77600 437.54 415.66 478.01
77051 14.32 13.60 15.64
7705126 3.43 3.26 3.75
7729026 84.31 80.09 92.10
77290 TC 501.01 475.96 547.35
7760026 84.31 80.09 92.10
77600TC 353.23 335.57 385.91
77051 TC 10.89 10.35 11.90
77052 14.32 13.60 15.64
77295 790.73 751.19 863.87
7729526 246.36 234.04 269.15
77605 787.56 748.18 860.41
7760526 109.62 104.14 119.76
7705226 3.43 3.26 3.75 77295 TC 544.38 517.16 594.73 77605TC 677.94 644.04 740.65
77052 TC 10.89 10.35 11.90
77053 89.29 84.83 97.55
77300 81.85 77.76 89.42
7730026 33.43 31.76 36.52
77610 738.86 701.92 807.21
7761026 81.66 77.58 89.22
7705326 19.84 18.85 21.68
77053 TC 69.45 65.98 75.88
77300 TC 48.42 46.00 52.90
77301 2,560.49 2,432.47 2,797.34
77610 TC 657.20 624.34 717.99
77615 1,045.90 993.61 1,142.65
77054 120.63 114.60 131.79 7730126 431.76 410.17 471.70 7761526 112.59 106.96 123.00
7705426 24.99 23.74 27.30
77054 TC 95.64 90.86 104.49
77301 TC 2,128.73 2,022.29 2,325.63
77305 83.65 79.47 91.39
77615TC 933.31 886.64 1,019.64
77620 458.69 435.76 501.12
77055 97.81 92.92 106.86
7705526 38.64 36.71 42.22
7730526 38.05 36.15 41.57
77305 TC 45.60 43.32 49.82
7762026 84.69 80.46 92.53
77620TC 374.00 355.30 408.60
77055 TC 59.18 56.22 64.65
77056 124.22 118.01 135.71
77310 115.77 109.98 126.48
7731026 56.78 53.94 62.03
77750 377.66 358.78 412.60
7775026 266.95 253.60 291.64
7705626 47.96 45.56 52.39 77310 TC 59.00 56.05 64.46 77750TC 110.72 105.18 120.96
77056 TC 76.25 72.44 83.31
77057 93.69 89.01 102.36
77315 168.78 160.34 184.39
7731526 84.31 80.09 92.10
77761 399.97 379.97 436.97
7776126 204.60 194.37 223.53
CODES: 76945TC - 7776126
# - These amounts apply when the service is performed in a facility setting.
C - The payment for the technical component is capped at the OPPS amount.
Limiting charge applies to unassigned claims by non-participating providers. All CPT codes and modifiers are bolded.
All Current Procedural Terminology (CPT) codes and descriptors are copyrighted 2008 by the American Medical Association.

77761TC
77762
7776226
77762TC
77763
7776326
77763TC
77776
7777626
77776TC
77777
7777726
77777TC
77778
7777826
77778TC
77785
7778526
77785TC
77786
7778626
77786TC
77787
7778726
77787TC
77789
7778926
77789TC
77790
7779026
77790TC
78000
7800026
78000TC
78001
7800126
78001TC
78003
7800326
78003TC
78006
7800626
78006TC
78007
7800726
78007TC
78010
7801026
78010TC
78011
7801126
78011TC
78015
7801526
78015TC
78016
7801626
78016TC
78018
7801826
78018TC
78020
7802026
78020TC
78070
7807026
78070TC
78075
7807526
78075TC
78102
7810226
78102TC
78103
7810326
78103TC
78104
7810426
78104TC
78110
7811026
78110TC
78111
7811126
78111TC
78120
7812026
78120TC
78121
7812126
78121TC
78122
7812226
78122TC
78130
7813026
78130TC
78135
7813526
78135TC
78140
7814026
78140TC
78185
7818526
78185TC
78190
7819026
78190TC
78191
7819126
78191TC
78195
7819526
78195TC
78201
7820126
78201TC
78202
7820226
78202TC
78205
7820526
78205TC
78206
7820626
78206TC
78215
7821526
78215TC
78216
7821626
78216TC
78220
7822026
78220TC
78223
7822326
78223TC
78230
7823026
78230TC
78231
7823126
78231TC
78232
7823226
78232TC
78258
7825826
78258TC
78261
7826126
78261TC
78262
7826226
78262TC
78264
7826426
78264TC
78270
7827026
78270TC
78271
7827126
78271TC
78272
7827226
78272TC
78278
7827826
78278TC
7828226
78290
7829026
78290TC
78291
7829126
78291TC
78300
7830026
78300TC
78305
7830526
78305TC
78306
7830626
78306TC
78315
7831526
78315TC
78320
7832026
78320TC
7841426
78428
7842826
78428TC
78445
7844526
78445TC
78456
7845626
78456TC
78457
7845726
78457TC
78458
7845826
78458TC
78459
7845926
78459TC
78460
7846026
78460TC
78461
7846126
78461TC
78464
7846426
78464TC
78465
7846526
78465TC
78466
7846626
78466TC
78468
7846826
78468TC






California - MEDICARE CARRIER 01192 FSY2009 LOCALITY 18 FEE SCHEDULE PAGE: 38
PROCEDURE PAR NONPAR CHARGE
CODE/MOD FEE FEE LIMIT
PROCEDURE PAR NONPAR CHARGE
CODE/MOD FEE FEE LIMIT
PROCEDURE PAR NONPAR CHARGE
CODE/MOD FEE FEE LIMIT
77761 TC 195.37 185.60 213.44
77762 541.86 514.77 591.99
7810426 44.60 42.37 48.73
78104 TC 245.40 233.13 268.10
78262 278.87 264.93 304.67
7826226 37.00 35.15 40.42
7776226 309.70 294.22 338.35 78110 90.46 85.94 98.83 78262TC 241.87 229.78 264.25
77762 TC 232.16 220.55 253.63
77763 763.52 725.34 834.14
7811026 10.52 9.99 11.49
78110 TC 79.94 75.94 87.33
78264 321.06 305.01 350.76
7826426 42.97 40.82 46.94
7776326 464.81 441.57 507.81
77763 TC 298.71 283.77 326.34
78111 115.55 109.77 126.24
7811126 12.53 11.90 13.69
78264TC 278.10 264.20 303.83
78270 93.32 88.65 101.95
77776 468.00 444.60 511.29 78111 TC 103.03 97.88 112.56 7827026 10.89 10.35 11.90
7777626 257.02 244.17 280.80
77776 TC 210.98 200.43 230.49
78120 102.69 97.56 112.19
7812026 12.90 12.26 14.10
78270TC 82.43 78.31 90.06
78271 94.20 89.49 102.91
77777 644.40 612.18 704.01
7777726 410.49 389.97 448.47
78120 TC 89.79 85.30 98.10
78121 124.17 117.96 135.65
7827126 10.45 9.93 11.42
78271TC 83.75 79.56 91.49
77777 TC 233.91 222.21 255.54
77778 918.73 872.79 1,003.71
7812126 17.61 16.73 19.24
78121 TC 106.56 101.23 116.41
78272 106.54 101.21 116.39
7827226 13.96 13.26 15.25
7777826 607.82 577.43 664.04 78122 153.44 145.77 167.64 78272TC 92.57 87.94 101.13
77778 TC 310.92 295.37 339.68
77785 215.52 204.74 235.45
7812226 24.99 23.74 27.30
78122 TC 128.46 122.04 140.35
C 78278 349.12 331.66 381.41
7827826 54.68 51.95 59.74
7778526 76.99 73.14 84.11
77785 TC 138.52 131.59 151.33
78130 178.93 169.98 195.48
7813026 33.93 32.23 37.06
C 78278 TC 294.44 279.72 321.68
7828226 21.03 19.98 22.98
77786 654.94 622.19 715.52 78130 TC 145.00 137.75 158.41 C 78290 333.39 316.72 364.23
7778626 172.90 164.26 188.90
77786 TC 482.04 457.94 526.63
78135 377.65 358.77 412.59
7813526 35.50 33.73 38.79
7829026 37.89 36.00 41.40
C 78290TC 295.51 280.73 322.84
77787 972.81 924.17 1,062.80
7778726 266.40 253.08 291.04
78135 TC 342.15 325.04 373.80
78140 173.01 164.36 189.01
78291 280.51 266.48 306.45
7829126 48.78 46.34 53.29
77787 TC 706.41 671.09 771.75
77789 118.90 112.96 129.90
7814026 33.93 32.23 37.06
78140 TC 139.08 132.13 151.95
78291TC 231.73 220.14 253.16
78300 196.98 187.13 215.20
7778926 61.77 58.68 67.48 78185 219.95 208.95 240.29 7830026 34.31 32.59 37.48
77789 TC 57.13 54.27 62.41
77790 98.89 93.95 108.04
7818526 22.23 21.12 24.29
78185 TC 197.73 187.84 216.02
78300TC 162.67 154.54 177.72
78305 261.83 248.74 286.05
7779026 56.78 53.94 62.03
77790 TC 42.11 40.00 46.00
C 78190 259.07 246.12 283.04
7819026 59.59 56.61 65.10
7830526 45.58 43.30 49.80
78305TC 216.26 205.45 236.27
78000 81.62 77.54 89.17 C 78190 TC 199.48 189.51 217.94 78306 290.34 275.82 317.19
7800026 10.52 9.99 11.49
78000 TC 71.10 67.55 77.68
78191 233.32 221.65 254.90
7819126 33.49 31.82 36.59
7830626 47.59 45.21 51.99
78306TC 242.75 230.61 265.20
78001 103.54 98.36 113.11
7800126 14.47 13.75 15.81
78191 TC 199.83 189.84 218.32
C 78195 384.98 365.73 420.59
C 78315 354.07 336.37 386.83
7831526 56.25 53.44 61.46
78001 TC 89.07 84.62 97.31
78003 89.53 85.05 97.81
7819526 66.68 63.35 72.85
C 78195 TC 318.30 302.39 347.75
C 78315TC 297.83 282.94 325.38
78320 296.61 281.78 324.05
7800326 17.98 17.08 19.64 78201 202.46 192.34 221.19 7832026 57.44 54.57 62.76
78003 TC 71.55 67.97 78.17
78006 256.03 243.23 279.71
7820126 23.73 22.54 25.92
78201 TC 178.73 169.79 195.26
78320TC 239.18 227.22 261.30
7841426 23.22 22.06 25.37
7800626 26.93 25.58 29.42
78006 TC 229.10 217.65 250.30
78202 233.65 221.97 255.27
7820226 27.68 26.30 30.25
78428 228.32 216.90 249.44
7842826 45.18 42.92 49.36
78007 154.63 146.90 168.94 78202 TC 205.97 195.67 225.02 78428TC 183.15 173.99 200.09
7800726 27.75 26.36 30.31
78007 TC 126.88 120.54 138.62
78205 278.63 264.70 304.41
7820526 39.46 37.49 43.11
78445 192.71 183.07 210.53
7844526 26.93 25.58 29.42
78010 177.91 169.01 194.36
7801026 21.41 20.34 23.39
78205 TC 239.18 227.22 261.30
C 78206 388.54 369.11 424.48
78445 TC 165.78 157.49 181.11
C 78456 285.00 270.75 311.36
78010 TC 156.50 148.68 170.98
C 78011 190.17 180.66 207.76
7820626 53.11 50.45 58.02
C 78206 TC 335.44 318.67 366.47
7845626 59.03 56.08 64.49
C 78456TC 225.98 214.68 246.88
7801126 24.99 23.74 27.30 78215 216.11 205.30 236.10 78457 219.84 208.85 240.18
C 78011 TC 165.18 156.92 180.46
78015 239.51 227.53 261.66
7821526 26.93 25.58 29.42
78215 TC 189.18 179.72 206.68
7845726 42.15 40.04 46.05
78457TC 177.69 168.81 194.13
7801526 37.07 35.22 40.50
78015 TC 202.43 192.31 221.16
78216 161.95 153.85 176.93
7821626 31.26 29.70 34.16
78458 242.07 229.97 264.47
7845826 49.97 47.47 54.59
78016 365.15 346.89 398.92 78216 TC 130.70 124.17 142.80 78458TC 192.09 182.49 209.86
7801626 45.35 43.08 49.54
78016 TC 319.79 303.80 349.37
78220 169.40 160.93 185.07
7822026 26.93 25.58 29.42
C 78459 1,464.81 1,391.57 1,600.31
7845926 86.49 82.17 94.50
78018 367.92 349.52 401.95
7801826 47.59 45.21 51.99
78220 TC 142.47 135.35 155.65
78223 361.62 343.54 395.07
C 78459 TC 1,378.32 1,309.40 1,505.81
78460 219.69 208.71 240.02
78018 TC 320.33 304.31 349.96
78020 104.93 99.68 114.63
7822326 46.39 44.07 50.68
78223 TC 315.22 299.46 344.38
7846026 48.03 45.63 52.47
78460TC 171.66 163.08 187.54
7802026 33.27 31.61 36.35 78230 183.83 174.64 200.84 78461 245.30 233.04 268.00
78020 TC 71.66 68.08 78.29
78070 201.26 191.20 219.88
7823026 24.54 23.31 26.81
78230 TC 159.29 151.33 174.03
7846126 68.84 65.40 75.21
78461TC 176.46 167.64 192.79
7807026 45.64 43.36 49.86
78070 TC 155.62 147.84 170.02
78231 155.81 148.02 170.22
7823126 28.50 27.08 31.14
78464 322.76 306.62 352.61
7846426 63.73 60.54 69.62
78075 481.09 457.04 525.60 78231 TC 127.31 120.94 139.08 78464TC 259.03 246.08 282.99
7807526 41.02 38.97 44.82
78075 TC 440.06 418.06 480.77
78232 159.08 151.13 173.80
7823226 26.18 24.87 28.60
78465 574.38 545.66 627.51
7846526 86.31 81.99 94.29
78102 188.18 178.77 205.59
7810226 30.51 28.98 33.33
78232 TC 132.90 126.26 145.20
78258 255.39 242.62 279.01
78465TC 488.07 463.67 533.22
78466 210.21 199.70 229.66
78102 TC 157.67 149.79 172.26
78103 252.66 240.03 276.03
7825826 41.47 39.40 45.31
78258 TC 213.92 203.22 233.70
7846626 39.59 37.61 43.25
78466TC 170.62 162.09 186.40
7810326 41.40 39.33 45.23 78261 282.78 268.64 308.94 78468 265.72 252.43 290.29
78103 TC 211.26 200.70 230.81
78104 290.00 275.50 316.83
7826126 38.26 36.35 41.80
78261 TC 244.52 232.29 267.13
7846826 47.25 44.89 51.62
78468TC 218.46 207.54 238.67
CODES: 77761TC - 78468TC
# - These amounts apply when the service is performed in a facility setting.
C - The payment for the technical component is capped at the OPPS amount.
Limiting charge applies to unassigned claims by non-participating providers. All CPT codes and modifiers are bolded.
All Current Procedural Terminology (CPT) codes and descriptors are copyrighted 2008 by the American Medical Association..

78469
7846926
78469TC
78472
7847226
78472TC
78473
7847326
78473TC
78478
7847826
78478TC
78480
7848026
78480TC
78481
7848126
78481TC
78483
7848326
78483TC
78491
7849126
78491TC
78492
7849226
78492TC
78494
7849426
78494TC
78496
7849626
78496TC
78580
7858026
78580TC
78584
7858426
78584TC
78585
7858526
78585TC
78586
7858626
78586TC
78587
7858726
78587TC
78588
7858826
78588TC
78591
7859126
78591TC
78593
7859326
78593TC
78594
7859426
78594TC
78596
7859626
78596TC
78600
7860026
78600TC
78601
7860126
78601TC
78605
7860526
78605TC
78606
7860626
78606TC
78607
7860726
78607TC
78608
7860826
78608TC
78610
7861026
78610TC
78630
7863026
78630TC
78635
7863526
78635TC
78645
7864526
78645TC
78647
7864726
78647TC
78650
7865026
78650TC
78660
7866026
78660TC
78700
7870026
78700TC
78701
7870126
78701TC
78707
7870726
78707TC
78708
7870826
78708TC
78709
7870926
78709TC
78710
7871026
78710TC
78725
7872526
78725TC
78730
7873026
78730TC
78740
7874026
78740TC
78761
7876126
78761TC
78800
7880026
78800TC
78801
7880126
78801TC
78802
7880226
78802TC
78803
7880326
78803TC
78804
7880426
78804TC
78805
7880526
78805TC
78806
7880626
78806TC
78807
7880726
78807TC
78808
78811
7881126
78811TC
78812
7881226
78812TC
78813
7881326
78813TC
78814
7881426
78814TC
78815
7881526
78815TC
78816
7881626
78816TC
79005
7900526
79005TC
79101
7910126
79101TC
79200
7920026
79200TC
7930026
79403
7940326
79403TC
79440
7944026
79440TC
79445
7944526
79445TC
80500
80500
80502
80502
8302026
8391226
8416526
8416626
8418126
8418226
85060
85097
85097
8539026
85396
8557626
86077
86077
86078
86078
86079
86079
8625526
8625626
8632026
8632526
8632726
8633426
8633526
86485
86486
86490
86510
86580
8716426
8720726
88104






California - MEDICARE CARRIER 01192 FSY2009 LOCALITY 18 FEE SCHEDULE PAGE: 39
PROCEDURE PAR NONPAR LIMITING
CODE/MOD FEE FEE CHARGE
PROCEDURE
CODE/MOD
PAR
FEE
NONPAR
FEE
LIMITING
CHARGE
PROCEDURE
CODE/MOD
PAR
FEE
NONPAR LIMITING
FEE CHARGE
78469 301.99 286.89 329.92
7846926 53.08 50.43 57.99
78469 TC 248.91 236.46 271.93
78472 306.88 291.54 335.27
7847226 56.07 53.27 61.26
78472 TC 250.81 238.27 274.01
78473 418.59 397.66 457.31
7847326 85.65 81.37 93.58
78473 TC 332.94 316.29 363.73
78478 67.76 64.37 74.03
7847826 29.96 28.46 32.73
78478 TC 37.80 35.91 41.30
78480 57.16 54.30 62.45
7848026 19.35 18.38 21.14
78480 TC 37.80 35.91 41.30
78481 268.46 255.04 293.30
7848126 58.43 55.51 63.84
78481 TC 210.03 199.53 229.46
78483 378.69 359.76 413.72
7848326 88.89 84.45 97.12
78483 TC 289.79 275.30 316.60
C 78491 1,465.98 1,392.68 1,601.58
7849126 87.66 83.28 95.77
C 78491 TC 1,378.32 1,309.40 1,505.81
C 78492 1,489.00 1,414.55 1,626.73
7849226 110.68 105.15 120.92
C 78492 TC 1,378.32 1,309.40 1,505.81
78494 334.06 317.36 364.96
7849426 68.66 65.23 75.01
78494 TC 265.39 252.12 289.94
78496 137.18 130.32 149.87
7849626 29.51 28.03 32.23
78496 TC 107.67 102.29 117.63
78580 243.29 231.13 265.80
7858026 41.02 38.97 44.82
78580 TC 202.27 192.16 220.98
78584 181.99 172.89 198.82
7858426 54.68 51.95 59.74
78584 TC 127.31 120.94 139.08
78585 402.32 382.20 439.53
7858526 60.49 57.47 66.09
78585 TC 341.83 324.74 373.45
78586 186.66 177.33 203.93
7858626 22.23 21.12 24.29
78586 TC 164.44 156.22 179.65
78587 235.11 223.35 256.85
7858726 27.37 26.00 29.90
78587 TC 207.74 197.35 226.95
78588 372.77 354.13 407.25
7858826 60.49 57.47 66.09
78588 TC 312.28 296.67 341.17
78591 189.32 179.85 206.83
7859126 22.23 21.12 24.29
78591 TC 167.09 158.74 182.55
78593 223.01 211.86 243.64
7859326 26.93 25.58 29.42
78593 TC 196.08 186.28 214.22
78594 261.01 247.96 285.15
7859426 29.32 27.85 32.03
78594 TC 231.69 220.11 253.13
78596 431.43 409.86 471.34
7859626 68.57 65.14 74.91
78596 TC 362.86 344.72 396.43
78600 203.19 193.03 221.98
7860026 24.61 23.38 26.89
78600 TC 178.58 169.65 195.10
78601 241.88 229.79 264.26
7860126 28.12 26.71 30.72
78601 TC 213.76 203.07 233.53
78605 225.84 214.55 246.73
7860526 29.76 28.27 32.51
78605 TC 196.08 186.28 214.22
78606 355.28 337.52 388.15
7860626 35.50 33.73 38.79
78606 TC 319.78 303.79 349.36
78607 422.72 401.58 461.82
7860726 67.95 64.55 74.23
78607 TC
C 78608
7860826
C 78608 TC
78610
7861026
78610 TC
78630
7863026
78630 TC
78635
7863526
78635 TC
C 78645
7864526
C 78645 TC
78647
7864726
78647 TC
78650
7865026
78650 TC
78660
7866026
78660 TC
78700
7870026
78700 TC
78701
7870126
78701 TC
78707
7870726
78707 TC
78708
7870826
78708 TC
78709
7870926
78709 TC
78710
7871026
78710 TC
78725
7872526
78725 TC
78730
7873026
78730 TC
78740
7874026
78740 TC
78761
7876126
78761 TC
78800
7880026
78800 TC
78801
7880126
78801 TC
78802
7880226
78802 TC
78803
7880326
78803 TC
78804
7880426
78804 TC
78805
7880526
78805 TC
78806
7880626
78806 TC
78807
354.77
1,318.10
82.80
1,235.30
206.20
17.30
188.90
377.08
37.89
339.19
343.44
34.09
309.35
258.15
31.70
226.44
396.51
49.53
346.98
368.28
33.93
334.34
190.52
29.32
161.21
201.49
24.99
176.51
241.57
26.93
214.64
278.48
53.11
225.37
223.65
67.20
156.45
410.38
78.10
332.29
276.75
36.70
240.06
116.12
20.59
95.53
90.27
9.75
80.52
239.59
31.99
207.60
239.23
39.46
199.77
213.63
36.10
177.53
286.67
43.92
242.75
376.60
47.59
329.02
413.93
60.49
353.44
667.25
59.45
607.80
213.76
40.21
173.55
394.40
47.59
346.81
414.52
337.03
1,252.20
78.66
1,173.54
195.89
16.44
179.46
358.23
36.00
322.23
326.27
32.39
293.88
245.24
30.12
215.12
376.68
47.05
329.63
349.87
32.23
317.62
180.99
27.85
153.15
191.42
23.74
167.68
229.49
25.58
203.91
264.56
50.45
214.10
212.47
63.84
148.63
389.86
74.20
315.68
262.91
34.87
228.06
110.31
19.56
90.75
85.76
9.26
76.49
227.61
30.39
197.22
227.27
37.49
189.78
202.95
34.30
168.65
272.34
41.72
230.61
357.77
45.21
312.57
393.23
57.47
335.77
633.89
56.48
577.41
203.07
38.20
164.87
374.68
45.21
329.47
393.79
387.58
1,440.03
90.46
1,349.57
225.27
18.91
206.38
411.96
41.40
370.56
375.21
37.25
337.96
282.03
34.64
247.39
433.18
54.11
379.07
402.35
37.06
365.26
208.14
32.03
176.12
220.13
27.30
192.83
263.91
29.42
234.50
304.24
58.02
246.22
244.34
73.42
170.92
448.34
85.33
363.03
302.35
40.10
262.27
126.86
22.49
104.36
98.62
10.65
87.96
261.75
34.95
226.80
261.36
43.11
218.25
233.39
39.45
193.95
313.19
47.98
265.20
411.44
51.99
359.46
452.21
66.09
386.14
728.97
64.95
664.02
233.53
43.93
189.60
430.88
51.99
378.89
452.86
7880726
78807 TC
78808
C 78811
7881126
C 78811 TC
C 78812
7881226
C 78812 TC
C 78813
7881326
C 78813 TC
C 78814
7881426
C 78814 TC
C 78815
7881526
C 78815 TC
C 78816
7881626
C 78816 TC
79005
7900526
79005 TC
79101
7910126
79101 TC
79200
7920026
79200 TC
7930026
79403
7940326
79403 TC
79440
7944026
79440 TC
79445
7944526
79445 TC
80500
# 80500
80502
# 80502
8302026
8391226
8416526
8416626
8418126
8418226
85060
85097
# 85097
8539026
85396
8557626
86077
# 86077
86078
# 86078
86079
# 86079
8625526
8625626
8632026
8632526
8632726
8633426
8633526
86485
86486
86490
86510
86580
8716426
8720726
88104
60.64
353.88
52.54
1,321.93
86.63
1,235.30
1,343.20
107.90
1,235.30
1,347.16
111.86
1,235.30
1,357.76
122.46
1,235.30
1,370.74
135.45
1,235.30
1,374.32
139.03
1,235.30
172.93
98.18
74.75
195.28
113.90
81.38
198.02
110.46
87.56
89.47
249.61
125.81
123.79
181.83
110.17
71.66
259.17
133.79
121.59
22.58
19.48
69.21
67.44
19.93
19.04
19.48
19.48
19.48
20.22
24.10
98.31
50.15
19.93
20.35
19.93
52.95
50.30
53.84
50.30
54.28
50.74
19.93
19.93
19.93
19.48
22.98
19.93
19.48
19.70
5.88
8.09
8.09
8.53
19.48
19.93
69.90
57.61 66.25
336.19 386.62
49.91 57.40
1,255.83 1,444.20
82.30 94.65
1,173.54 1,349.57
1,276.04 1,467.45
102.51 117.89
1,173.54 1,349.57
1,279.80 1,471.77
106.27 122.21
1,173.54 1,349.57
1,289.87 1,483.35
116.34 133.79
1,173.54 1,349.57
1,302.20 1,497.53
128.68 147.98
1,173.54 1,349.57
1,305.60 1,501.44
132.08 151.89
1,173.54 1,349.57
164.28 188.92
93.27 107.26
71.01 81.66
185.52 213.35
108.21 124.44
77.31 88.91
188.12 216.34
104.94 120.68
83.18 95.66
85.00 97.75
237.13 272.70
119.52 137.45
117.60 135.24
172.74 198.65
104.66 120.36
68.08 78.29
246.21 283.14
127.10 146.17
115.51 132.84
21.45 24.67
18.51 21.29
65.75 75.61
64.07 73.68
18.93 21.77
18.09 20.80
18.51 21.29
18.51 21.29
18.51 21.29
19.21 22.09
22.90 26.34
93.39 107.40
47.64 54.79
18.93 21.77
19.33 22.23
18.93 21.77
50.30 57.85
47.79 54.96
51.15 58.82
47.79 54.96
51.57 59.31
48.20 55.43
18.93 21.77
18.93 21.77
18.93 21.77
18.51 21.29
21.83 25.10
18.93 21.77
18.51 21.29
18.72 21.53
5.59 6.43
7.69 8.84
7.69 8.84
8.10 9.32
18.51 21.29
18.93 21.77
66.41 76.37
CODES: 78469 - 88104
# - These amounts apply when the service is performed in a facility setting.
C - The payment for the technical component is capped at the OPPS amount.
Limiting charge applies to unassigned claims by non-participating providers. All CPT codes and modifiers are bolded.
All Current Procedural Terminology (CPT) codes and descriptors are copyrighted 2008 by the American Medical Association.

8810426
88104TC
88106
8810626
88106TC
88107
8810726
88107TC
88108
8810826
88108TC
88112
8811226
88112TC
88125
8812526
88125TC
88141
88160
8816026
88160TC
88161
8816126
88161TC
88162
8816226
88162TC
88172
8817226
88172TC
88173
8817326
88173TC
88182
8818226
88182TC
88184
88185
88187
88188
88189
88291
88300
8830026
88300TC
88302
8830226
88302TC
88304
8830426
88304TC
88305
8830526
88305TC
88307
8830726
88307TC
88309
8830926
88309TC
88311
8831126
88311TC
88312
8831226
88312TC
88313
8831326
88313TC
88314
8831426
88314TC
88318
8831826
88318TC
88319
8831926
88319TC
88321
88321
88323
8832326
88323TC
88325
88325
88329
88329
88331
8833126
88331TC
88332
8833226
88332TC
88333
8833326
88333TC
88334
8833426
88334TC
88342
8834226
88342TC
88346
8834626
88346TC
88347
8834726
88347TC
88348
8834826
88348TC
88349
8834926
88349TC
88355
8835526
88355TC
88356
8835626
88356TC
88358
8835826
88358TC
88360
8836026
88360TC
88361
8836126
88361TC
88362
8836226
88362TC
88365
8836526
88365TC
88367
8836726
88367TC
88368
8836826
88368TC
8837126
8837226
88380
8838026
88380TC
88381
8838126
88381TC
88385
8838526
88385TC
88386
8838626
88386TC
89049
89049
8906026
89100
89100
89105
89105
89130
89130
89132
89132
89135
89135
89136
89136
89140
89140
89141
89141
89220
89230
90465
90466
90466
90467
90467
90468
90468
90471
90472
90472
90473
90473
90474
90474
90801
90801
90802
90802
90804
90804
90805
90805
90806
90806
90807
90807
90808
90808
90809
90809
90810
90810
90811
90811
90812
90812
90813
90813
90814
90814
90815
90815
90816
90817
90818
90819
90821
90822
90823
90824
90826
90827
90828
90829
90845






California - MEDICARE CARRIER 01192 FSY2009 LOCALITY 18 FEE SCHEDULE PAGE: 40
PROCEDURE PAR NONPAR CHARGE
CODE/MOD FEE FEE LIMIT
PROCEDURE PAR NONPAR CHARGE
CODE/MOD FEE FEE LIMIT
PROCEDURE PAR NONPAR CHARGE
CODE/MOD FEE FEE LIMIT
8810426 29.56 28.08 32.29
88104 TC 40.34 38.32 44.07
88319 TC 134.89 128.15 147.37
88321 95.34 90.57 104.16
88386TC 692.88 658.24 756.98
89049 278.30 264.39 304.05
88106 88.02 83.62 96.16 # 88321 84.74 80.50 92.58 # 89049 72.86 69.22 79.60
8810626 29.56 28.08 32.29
88106 TC 58.46 55.54 63.87
88323 159.98 151.98 174.78
8832326 91.36 86.79 99.81
8906026 19.93 18.93 21.77
89100 288.04 273.64 314.69
88107 110.39 104.87 120.60
8810726 40.89 38.85 44.68
88323 TC 68.62 65.19 74.97
88325 212.53 201.90 232.19
# 89100 42.84 40.70 46.81
89105 296.81 281.97 324.27
88107 TC 69.50 66.03 75.93 # 88325 132.12 125.51 144.34 # 89105 36.58 34.75 39.96
88108 83.16 79.00 90.85
8810826 29.56 28.08 32.29
88329 54.90 52.16 59.98
# 88329 35.90 34.11 39.23
89130 251.20 238.64 274.44
# 89130 31.61 30.03 34.53
88108 TC 53.60 50.92 58.56
88112 114.83 109.09 125.45
88331 99.57 94.59 108.78
8833126 64.40 61.18 70.36
89132 288.42 274.00 315.10
# 89132 20.68 19.65 22.60
8811226 60.35 57.33 65.93
88112 TC 54.48 51.76 59.52
88331 TC 35.18 33.42 38.43
88332 44.08 41.88 48.16
89135 340.53 323.50 372.03
# 89135 56.45 53.63 61.67
88125 24.04 22.84 26.27 8833226 31.57 29.99 34.49 89136 244.10 231.90 266.69
8812526 14.03 13.33 15.33
88125 TC 10.01 9.51 10.94
88332 TC 12.51 11.88 13.66
88333 102.16 97.05 111.61
# 89136 19.22 18.26 21.00
89140 280.78 266.74 306.75
88141 30.05 28.55 32.83
88160 58.81 55.87 64.25
8833326 64.33 61.11 70.28
88333 TC 37.83 35.94 41.33
# 89140 56.33 53.51 61.54
89141 291.25 276.69 318.19
8816026 26.42 25.10 28.87 88334 61.70 58.62 67.41 # 89141 53.55 50.87 58.50
88160 TC 32.39 30.77 35.39
88161 61.46 58.39 67.15
8833426 38.59 36.66 42.16
88334 TC 23.11 21.95 25.24
89220 17.81 16.92 19.46
89230 4.56 4.33 4.98
8816126 25.98 24.68 28.38
88161 TC 35.48 33.71 38.77
88342 113.77 108.08 124.29
8834226 44.27 42.06 48.37
90465 24.35 23.13 26.60
90466 11.67 11.09 12.75
88162 88.75 84.31 96.96
8816226 40.45 38.43 44.19
88342 TC 69.50 66.03 75.93
88346 114.15 108.44 124.71
# 90466 8.57 8.14 9.36
90467 15.51 14.73 16.94
88162 TC 48.30 45.89 52.77 8834626 45.09 42.84 49.27 # 90467 10.21 9.70 11.16
88172 59.03 56.08 64.49
8817226 31.94 30.34 34.89
88346 TC 69.06 65.61 75.45
88347 88.97 84.52 97.20
90468 11.22 10.66 12.26
# 90468 8.13 7.72 8.88
88172 TC 27.09 25.74 29.60
88173 150.98 143.43 164.94
8834726 42.88 40.74 46.85
88347 TC 46.09 43.79 50.36
90471 24.35 23.13 26.60
90472 11.67 11.09 12.75
8817326 73.52 69.84 80.32 88348 744.39 707.17 813.25 # 90472 8.57 8.14 9.36
88173 TC 77.46 73.59 84.63
88182 117.54 111.66 128.41
8834826 79.64 75.66 87.01
88348 TC 664.75 631.51 726.24
90473 15.51 14.73 16.94
# 90473 8.88 8.44 9.71
8818226 37.73 35.84 41.22
88182 TC 79.80 75.81 87.18
88349 353.67 335.99 386.39
8834926 40.89 38.85 44.68
90474 9.90 9.41 10.82
# 90474 8.13 7.72 8.88
88184 95.57 90.79 104.41
88185 56.69 53.86 61.94
88349 TC 312.78 297.14 341.71
88355 275.14 261.38 300.59
90801 167.84 159.45 183.37
# 90801 137.35 130.48 150.05
88187 69.47 66.00 75.90 8835526 92.70 88.07 101.28 90802 178.66 169.73 195.19
88188 85.39 81.12 93.29
88189 108.32 102.90 118.34
88355 TC 182.44 173.32 199.32
88356 327.88 311.49 358.21
# 90802 147.74 140.35 161.40
90804 73.21 69.55 79.98
88291 31.15 29.59 34.03
88300 27.44 26.07 29.98
8835626 147.35 139.98 160.98
88356 TC 180.52 171.49 197.21
# 90804 60.68 57.65 66.30
90805 81.36 77.29 88.88
8830026 4.62 4.39 5.05 88358 86.10 81.80 94.07 # 90805 68.38 64.96 74.70
88300 TC 22.82 21.68 24.93
88302 57.89 55.00 63.25
8835826 48.29 45.88 52.76
88358 TC 37.82 35.93 41.32
90806 100.99 95.94 110.33
# 90806 93.10 88.45 101.72
8830226 6.94 6.59 7.58
88302 TC 50.95 48.40 55.66
88360 136.84 130.00 149.50
8836026 57.62 54.74 62.95
90807 113.63 107.95 124.14
# 90807 101.10 96.05 110.46
88304 73.19 69.53 79.96
8830426 11.64 11.06 12.72
88360 TC 79.22 75.26 86.55
88361 173.83 165.14 189.91
90808 148.00 140.60 161.69
# 90808 140.11 133.10 153.07
88304 TC 61.55 58.47 67.24 8836126 61.78 58.69 67.49 90809 160.18 152.17 175.00
88305 121.20 115.14 132.41
8830526 40.07 38.07 43.78
88361 TC 112.04 106.44 122.41
88362 300.99 285.94 328.83
# 90809 148.11 140.70 161.81
90810 77.37 73.50 84.53
88305 TC 81.13 77.07 88.63
88307 242.11 230.00 264.50
8836226 114.13 108.42 124.68
88362 TC 186.86 177.52 204.15
# 90810 66.24 62.93 72.37
90811 90.65 86.12 99.04
8830726 85.29 81.03 93.18 88365 180.37 171.35 197.05 # 90811 74.41 70.69 81.29
88307 TC 156.82 148.98 171.33
88309 361.91 343.81 395.38
8836526 61.83 58.74 67.55
88365 TC 118.54 112.61 129.50
90812 110.43 104.91 120.65
# 90812 98.83 93.89 107.97
8830926 146.77 139.43 160.34
88309 TC 215.14 204.38 235.04
88367 280.27 266.26 306.20
8836726 66.01 62.71 72.12
90813 123.07 116.92 134.46
# 90813 106.83 101.49 116.71
88311 20.19 19.18 22.06
8831126 12.84 12.20 14.03
88367 TC 214.25 203.54 234.07
88368 244.70 232.47 267.34
90814 159.76 151.77 174.54
# 90814 148.63 141.20 162.38
88311 TC 7.36 6.99 8.04 8836826 69.33 65.86 75.74 90815 169.62 161.14 185.31
88312 115.69 109.91 126.40
8831226 28.37 26.95 30.99
88368 TC 175.37 166.60 191.59
8837126 19.48 18.51 21.29
# 90815 153.38 145.71 167.57
90816 66.90 63.56 73.09
88312 TC 87.33 82.96 95.40
88313 85.58 81.30 93.50
8837226 19.48 18.51 21.29
88380 225.66 214.38 246.54
90817 74.13 70.42 80.98
90818 99.38 94.41 108.57
8831326 12.39 11.77 13.54 8838026 82.69 78.56 90.34 90819 106.46 101.14 116.31
88313 TC 73.19 69.53 79.96
88314 103.33 98.16 112.88
88380 TC 142.97 135.82 156.19
88381 250.30 237.79 273.46
90821 146.33 139.01 159.86
90822 153.71 146.02 167.92
8831426 24.10 22.90 26.34
88314 TC 79.22 75.26 86.55
8838126 62.83 59.69 68.64
88381 TC 187.47 178.10 204.82
90823 72.16 68.55 78.83
90824 80.16 76.15 87.57
88318 116.93 111.08 127.74
8831826 22.09 20.99 24.14
88385 622.67 591.54 680.27
8838526 73.08 69.43 79.84
90826 105.35 100.08 115.09
90827 111.73 106.14 122.06
88318 TC 94.84 90.10 103.62 88385 TC 549.59 522.11 600.43 90828 152.06 144.46 166.13
88319 162.88 154.74 177.95
8831926 27.99 26.59 30.58
88386 797.59 757.71 871.37
8838626 104.72 99.48 114.40
90829 158.67 150.74 173.35
90845 87.81 83.42 95.93
CODES: 8810426 - 90845
# - These amounts apply when the service is performed in a facility setting.
C - The payment for the technical component is capped at the OPPS amount.
Limiting charge applies to unassigned claims by non-participating providers. All CPT codes and modifiers are bolded.
All Current Procedural Terminology (CPT) codes and descriptors are copyrighted 2008 by the American Medical Association..

90845
90846
90846
90847
90847
90849
90849
90853
90853
90857
90857
90862
90862
90865
90865
90870
90870
90880
90880
90901
90901
90911
90911
90935
90937
90945
90947
90951
90954
90955
90956
90957
90958
90959
90960
90961
90962
90963
90964
90965
90966
90967
90968
90969
90970
90997
91000
9100026
91000TC
91010
9101026
91010TC
91011
9101126
91011TC
91012
9101226
91012TC
91020
9102026
91020TC
91022
9102226
91022TC
91030
9103026
91030TC
91034
9103426
91034TC
91035
9103526
91035TC
91037
9103726
91037TC
91038
9103826
91038TC
91040
9104026
91040TC
91052
9105226
91052TC
91055
9105526
91055TC
91065
9106526
91065TC
91105
91105
91110
9111026
91110TC
91111
9111126
91111TC
91120
9112026
91120TC
91122
9112226
91122TC
9113226
9113326
92002
92002
92004
92004
92012
92012
92014
92014
92018
92019
92020
92020
92025
9202526
92025TC
92060
9206026
92060TC
92065
9206526
92065TC
92070
92070
92081
9208126
92081TC
92082
9208226
92082TC
92083
9208326
92083TC
92100
92100
92120
92120
92130
92130
92135
9213526
92135TC
92136
9213626
92136TC
92140
92140
92225
92225
92226
92226
92230
92230
92235
9223526
92235TC
92240
9224026
92240TC
92250
9225026
92250TC
92260
92260
92265
9226526
92265TC
92270
9227026
92270TC
92275
9227526
92275TC
92283
9228326
92283TC
92284
9228426
92284TC
92285
9228526
92285TC
92286
9228626
92286TC
92287
92287
92311
92311
92312
92312
92313
92313
92315
92315
92316
92316
92317
92317
92325
92326
92502
92504
92504
92506
92506
92507
92507
92508
92508
92511
92511
92512
92512
92516
92516
92520
92520
92526
92526
92541
9254126
92541TC
92542
9254226






California - MEDICARE CARRIER 01192 FSY2009 LOCALITY 18 FEE SCHEDULE PAGE: 41
PROCEDURE PAR NONPAR LIMITING
CODE/MOD FEE FEE CHARGE
PROCEDURE
CODE/MOD
PAR
FEE
NONPAR
FEE
LIMITING
CHARGE
PROCEDURE PAR
CODE/MOD FEE
NONPAR LIMITING
FEE CHARGE
# 90845 85.60 81.32 93.52
90846 94.17 89.46 102.88
# 90846 91.52 86.94 99.98
90847 117.56 111.68 128.43
# 90847 109.61 104.13 119.75
90849 35.99 34.19 39.32
# 90849 32.45 30.83 35.45
90853 33.93 32.23 37.06
# 90853 31.72 30.13 34.65
90857 38.52 36.59 42.08
# 90857 33.66 31.98 36.78
90862 60.99 57.94 66.63
# 90862 48.62 46.19 53.12
90865 168.87 160.43 184.49
# 90865 142.36 135.24 155.53
90870 154.36 146.64 168.64
# 90870 91.19 86.63 99.62
90880 114.60 108.87 125.20
# 90880 104.88 99.64 114.59
90901 38.06 36.16 41.58
# 90901 21.28 20.22 23.25
90911 98.33 93.41 107.42
# 90911 49.29 46.83 53.85
90935 72.59 68.96 79.30
90937 118.36 112.44 129.31
90945 75.29 71.53 82.26
90947 121.12 115.06 132.32
90951 1,046.56 994.23 1,143.36
90954 850.82 808.28 929.52
90955 484.37 460.15 529.17
90956 328.16 311.75 358.51
90957 686.08 651.78 749.55
90958 463.95 440.75 506.86
90959 304.21 289.00 332.35
90960 308.10 292.70 336.61
90961 247.95 235.55 270.88
90962 178.60 169.67 195.12
90963 589.83 560.34 644.39
90964 488.81 464.37 534.03
90965 465.01 441.76 508.02
90966 244.86 232.62 267.51
90967 21.38 20.31 23.36
90968 16.41 15.59 17.93
90969 16.04 15.24 17.53
90970 8.64 8.21 9.44
90997 95.56 90.78 104.40
91000 101.47 96.40 110.86
9100026 38.88 36.94 42.48
91000 TC 62.59 59.46 68.38
91010 216.53 205.70 236.56
9101026 72.53 68.90 79.24
91010 TC 144.00 136.80 157.32
91011 291.16 276.60 318.09
9101126 89.27 84.81 97.53
91011 TC 201.88 191.79 220.56
91012 296.28 281.47 323.69
9101226 85.72 81.43 93.64
91012 TC 210.57 200.04 230.05
91020 263.72 250.53 288.11
9102026 83.05 78.90 90.74
91020 TC 180.68 171.65 197.40
91022 215.12 204.36 235.01
9102226 85.70 81.42 93.63
91022 TC 129.42 122.95 141.39
91030 157.85 149.96 172.45
9103026 53.88 51.19 58.87
91030 TC 103.96 98.76 113.57
91034 229.44 217.97 250.67
9103426 56.27 53.46 61.48
91034 TC 173.16 164.50 189.18
91035 545.64 518.36 596.11
9103526 91.92 87.32 100.42
91035 TC 453.72 431.03 495.68
91037 182.61 173.48 199.50
9103726 57.16 54.30 62.45
91037 TC 125.45 119.18 137.06
91038 159.21 151.25 173.94
9103826
91038TC
91040
9104026
91040TC
91052
9105226
91052 TC
91055
9105526
91055 TC
91065
9106526
91065 TC
91105
# 91105
91110
9111026
91110 TC
91111
9111126
91111 TC
91120
9112026
91120 TC
91122
9112226
91122 TC
9113226
9113326
92002
# 92002
92004
# 92004
92012
# 92012
92014
# 92014
92018
92019
92020
# 92020
92025
9202526
92025 TC
92060
9206026
92060 TC
92065
9206526
92065 TC
92070
# 92070
92081
9208126
92081 TC
92082
9208226
92082 TC
92083
9208326
92083 TC
92100
# 92100
92120
# 92120
92130
# 92130
92135
9213526
92135 TC
92136
9213626
92136 TC
92140
# 92140
# 92225
64.69
94.52
443.72
58.92
384.79
140.68
43.79
96.90
151.31
49.56
101.76
76.42
11.33
65.09
91.64
17.85
1,047.03
211.29
835.74
830.73
59.18
771.55
454.92
52.59
402.33
262.97
97.62
165.35
30.71
39.35
76.03
46.87
141.95
97.33
80.19
49.70
116.48
76.28
138.75
68.61
26.55
20.37
35.37
19.17
16.20
60.80
37.97
22.82
48.93
19.04
29.89
68.83
38.35
56.07
19.55
36.52
74.54
23.88
50.66
85.18
27.46
57.73
92.12
49.26
75.62
43.80
84.01
44.69
49.07
19.62
29.45
87.98
30.28
57.70
60.15
26.57
20.74
61.46
89.79
421.53
55.97
365.55
133.65
41.60
92.06
143.74
47.08
96.67
72.60
10.76
61.84
87.06
16.96
994.68
200.73
793.95
789.19
56.22
732.97
432.17
49.96
382.21
249.82
92.74
157.08
29.17
37.38
72.23
44.53
134.85
92.46
76.18
47.22
110.66
72.47
131.81
65.18
25.22
19.35
33.60
18.21
15.39
57.76
36.07
21.68
46.48
18.09
28.40
65.39
36.43
53.27
18.57
34.69
70.81
22.69
48.13
80.92
26.09
54.84
87.51
46.80
71.84
41.61
79.81
42.46
46.62
18.64
27.98
83.58
28.77
54.82
57.14
25.24
19.70
70.68
103.26
484.76
64.37
420.38
153.70
47.84
105.87
165.30
54.14
111.17
83.49
12.37
71.12
100.12
19.50
1,143.88
230.84
913.04
907.57
64.65
842.92
497.00
57.45
439.54
287.29
106.65
180.64
33.55
42.99
83.06
51.21
155.08
106.33
87.61
54.30
127.26
83.34
151.58
74.96
29.00
22.25
38.64
20.94
17.70
66.42
41.48
24.93
53.45
20.80
32.66
75.20
41.89
61.26
21.36
39.89
81.43
26.09
55.35
93.06
30.00
63.07
100.64
53.82
82.62
47.85
91.78
48.83
53.61
21.44
32.18
96.12
33.09
63.04
65.71
29.03
22.66
92225 25.16
92226 22.84
# 92226 18.42
92230 62.87
# 92230 32.39
92235 136.56
9223526 45.57
92235 TC 90.99
C 92240 235.37
9224026 62.05
C 92240 TC 173.32
92250 76.75
9225026 23.88
92250 TC 52.87
92260 18.40
# 92260 11.33
92265 80.75
9226526 42.62
92265 TC 38.13
92270 93.72
9227026 43.21
92270 TC 50.51
92275 141.43
9227526 56.46
92275 TC 84.97
92283 49.38
9228326 9.32
92283 TC 40.05
92284 66.14
9228426 12.39
92284 TC 53.75
92285 45.20
9228526 11.33
92285 TC 33.87
92286 128.44
9228626 36.41
92286 TC 92.04
92287 120.68
# 92287 44.69
92311 96.65
# 92311 56.44
92312 109.59
# 92312 66.29
92313 93.88
# 92313 49.26
92315 69.32
# 92315 23.37
92316 89.73
# 92316 37.16
92317 71.53
# 92317 22.93
92325 32.10
92326 43.71
92502 101.00
92504 32.23
# 92504 10.14
92506 174.10
# 92506 47.30
92507 71.35
# 92507 28.06
92508 33.91
# 92508 14.47
92511 171.14
# 92511 63.34
92512 66.30
# 92512 29.62
92516 69.45
# 92516 23.95
92520 66.14
# 92520 41.84
92526 91.92
# 92526 29.18
92541 66.55
9254126 21.78
92541 TC 44.76
92542 69.81
9254226 17.98
23.90 27.49
21.70 24.96
17.50 20.13
59.73 68.69
30.77 35.39
129.73 149.19
43.29 49.78
86.44 99.41
223.60 257.14
58.95 67.79
164.65 189.35
72.91 83.85
22.69 26.09
50.23 57.76
17.48 20.10
10.76 12.37
76.71 88.22
40.49 46.56
36.22 41.65
89.03 102.38
41.05 47.21
47.98 55.18
134.36 154.51
53.64 61.69
80.72 92.83
46.91 53.95
8.85 10.18
38.05 43.76
62.83 72.25
11.77 13.54
51.06 58.72
42.94 49.38
10.76 12.37
32.18 37.01
122.02 140.32
34.59 39.78
87.44 100.56
114.65 131.85
42.46 48.83
91.82 105.59
53.62 61.66
104.11 119.73
62.98 72.43
89.19 102.57
46.80 53.82
65.85 75.73
22.20 25.53
85.24 98.03
35.30 40.60
67.95 78.14
21.78 25.05
30.50 35.08
41.52 47.75
95.95 110.34
30.62 35.21
9.63 11.07
165.40 190.21
44.94 51.68
67.78 77.95
26.66 30.66
32.21 37.04
13.75 15.81
162.58 186.97
60.17 69.20
62.99 72.44
28.14 32.36
65.98 75.88
22.75 26.16
62.83 72.25
39.75 45.71
87.32 100.42
27.72 31.88
63.22 72.70
20.69 23.79
42.52 48.90
66.32 76.27
17.08 19.64
CODES: 90845 - 9254226
# - These amounts apply when the service is performed in a facility setting.
C - The payment for the technical component is capped at the OPPS amount.
Limiting charge applies to unassigned claims by non-participating providers. All CPT codes and modifiers are bolded.
All Current Procedural Terminology (CPT) codes and descriptors are copyrighted 2008 by the American Medical Association.

92542TC
92543
9254326
92543TC
92544
9254426
92544TC
92545
9254526
92545TC
92546
9254626
92546TC
92547
92548
9254826
92548TC
92552
92553
92555
92556
92557
92557
92561
92562
92563
92564
92565
92567
92567
92568
92569
92571
92572
92575
92576
92577
92579
92579
92582
92583
92584
92585
9258526
92585TC
92586
92587
9258726
92587TC
92588
9258826
92588TC
92596
92597
92597
92601
92601
92602
92602
92603
92603
92604
92604
92607
92608
92609
92610
92611
92612
92612
92613
92614
92614
92615
92616
92616
92617
92620
92621
92625
92626
92627
92640
92950
92950
92953
92960
92960
92961
92970
92971
92973
92974
92975
92977
92978
9297826
92978TC
92979
9297926
92979TC
92980
92981
92982
92984
92986
92987
92990
92995
92996
92997
92998
93000
93005
93010
93012
93014
93015
93016
93017
93018
93024
9302426
93024TC
93025
9302526
93025TC
93040
93041
93042
93224
93225
93226
93227
93228
93230
93231
93232
93233
93235
93236
93237
93268
93270
93271
93272
93278
9327826
93278TC
93279
9327926
93279TC
93280
9328026
93280TC
93281
9328126
93281TC
93282
9328226
93282TC
93283
9328326
93283TC
93284
9328426
93284TC
93285
9328526
93285TC
93286
9328626
93286TC
93287
9328726
93287TC
93288
9328826
93288TC
93289
9328926
93289TC
93290
9329026
93290TC
93291
9329126
93291TC
93292
9329226
93292TC
93293
9329326
93293TC
93294
93295
93296
93297
93298
93303
9330326
93303TC
93304
9330426
93304TC
93306
9330626
93306TC
93307
9330726
93307TC
93308
9330826
93308TC
93312
9331226
93312TC
93313
93314
9331426
93314TC
93315
9331526
93315TC
93316
93317
9331726
93317TC
9331826
93320
9332026






California - MEDICARE CARRIER 01192 FSY2009 LOCALITY 18 FEE SCHEDULE PAGE: 42
PROCEDURE PAR NONPAR CHARGE
CODE/MOD FEE FEE LIMIT
PROCEDURE PAR NONPAR CHARGE
CODE/MOD FEE FEE LIMIT
PROCEDURE PAR NONPAR CHARGE
CODE/MOD FEE FEE LIMIT
92542 TC 51.83 49.24 56.63
92543 32.61 30.98 35.63
92620 76.92 73.07 84.03
92621 17.85 16.96 19.50
93280TC 27.38 26.01 29.91
93281 87.66 83.28 95.77
9254326 5.81 5.52 6.35 92625 61.28 58.22 66.95 9328126 55.58 52.80 60.72
92543 TC 26.80 25.46 29.28
92544 56.14 53.33 61.33
92626 85.98 81.68 93.93
92627 21.07 20.02 23.02
93281TC 32.09 30.49 35.06
93282 80.78 76.74 88.25
9254426 14.03 13.33 15.33
92544 TC 42.11 40.00 46.00
92640 79.02 75.07 86.33
92950 301.52 286.44 329.41
9328226 51.78 49.19 56.57
93282TC 28.99 27.54 31.67
92545 52.80 50.16 57.68 # 92950 187.53 178.15 204.87 93283 98.29 93.38 107.39
9254526 12.46 11.84 13.62
92545 TC 40.34 38.32 44.07
92953 12.75 12.11 13.93
92960 296.37 281.55 323.78
9328326 65.32 62.05 71.36
93283TC 32.97 31.32 36.02
92546 95.70 90.92 104.56
9254626 15.60 14.82 17.04
# 92960 147.48 140.11 161.13
92961 286.34 272.02 312.82
93284 115.08 109.33 125.73
9328426 77.69 73.81 84.88
92546 TC 80.11 76.10 87.52
92547 6.16 5.85 6.73
92970 196.95 187.10 215.17
92971 114.14 108.43 124.69
93284 TC 37.39 35.52 40.85
93285 54.84 52.10 59.92
92548 107.07 101.72 116.98 92973 202.72 192.58 221.47 9328526 32.47 30.85 35.48
9254826 27.31 25.94 29.83
92548 TC 79.76 75.77 87.14
92974 185.88 176.59 203.08
92975 444.94 422.69 486.09
93285TC 22.37 21.25 24.44
93286 30.98 29.43 33.84
92552 25.46 24.19 27.82
92553 33.99 32.29 37.13
92977 157.37 149.50 171.93
92978 318.20 302.29 347.63
9328626 16.26 15.45 17.77
93286TC 14.72 13.98 16.08
92555 18.83 17.89 20.57 9297826 109.08 103.63 119.17 93287 40.44 38.42 44.18
92556 29.13 27.67 31.82
92557 49.42 46.95 53.99
92978 TC 212.24 201.63 231.87
92979 192.00 182.40 209.76
9328726 23.81 22.62 26.01
93287TC 16.62 15.79 18.16
# 92557 46.33 44.01 50.61
92561 33.11 31.45 36.17
9297926 88.06 83.66 96.21
92979 TC 107.16 101.80 117.07
93288 49.41 46.94 53.98
9328826 26.60 25.27 29.06
92562 26.79 25.45 29.27
92563 24.13 22.92 26.36
92980 924.72 878.48 1,010.25
92981 256.94 244.09 280.70
93288TC 22.81 21.67 24.92
93289 75.36 71.59 82.33
92564 23.10 21.95 25.24 92982 685.81 651.52 749.25 9328926 47.98 45.58 52.42
92565 14.86 14.12 16.24
92567 19.41 18.44 21.21
92984 183.43 174.26 200.40
92986 1,530.51 1,453.98 1,672.08
93289TC 27.38 26.01 29.91
93290 35.56 33.78 38.85
# 92567 17.20 16.34 18.79
92568 19.56 18.58 21.37
92987 1,584.21 1,505.00 1,730.75
92990 1,218.79 1,157.85 1,331.53
9329026 22.91 21.76 25.02
93290TC 12.65 12.02 13.82
92569 15.74 14.95 17.19 92995 755.87 718.08 825.79 93291 47.20 44.84 51.57
92571 19.27 18.31 21.06
92572 20.61 19.58 22.52
92996 197.76 187.87 216.05
92997 693.35 658.68 757.48
9329126 26.89 25.55 29.38
93291 TC 20.31 19.29 22.18
92575 41.67 39.59 45.53
92576 24.87 23.63 27.17
92998 356.28 338.47 389.24
93000 24.04 22.84 26.27
93292 42.34 40.22 46.25
9329226 26.60 25.27 29.06
92577 20.14 19.13 22.00
92579 47.90 45.51 52.34
93005 14.28 13.57 15.61
93010 9.77 9.28 10.67
93292TC 15.74 14.95 17.19
93293 69.24 65.78 75.65
# 92579 44.37 42.15 48.47 93012 220.38 209.36 240.76 9329326 18.34 17.42 20.03
92582 48.57 46.14 53.06
92583 38.99 37.04 42.60
93014 30.27 28.76 33.07
93015 115.72 109.93 126.42
93293 TC 50.91 48.36 55.61
93294 40.30 38.29 44.03
92584 78.99 75.04 86.30
92585 116.04 110.24 126.78
93016 26.75 25.41 29.22
93017 71.23 67.67 77.82
93295 72.92 69.27 79.66
93296 44.47 42.25 48.59
9258526 27.60 26.22 30.15 93018 17.74 16.85 19.38 93297 27.61 26.23 30.16
92585 TC 88.45 84.03 96.63
92586 73.42 69.75 80.21
93024 139.75 132.76 152.67
9302426 68.95 65.50 75.33
93298 32.47 30.85 35.48
93303 254.57 241.84 278.12
92587 44.59 42.36 48.71
9258726 7.38 7.01 8.06
93024 TC 70.80 67.26 77.35
93025 254.01 241.31 277.51
9330326 75.15 71.39 82.10
93303 TC 179.42 170.45 196.02
92587 TC 37.21 35.35 40.65
92588 72.36 68.74 79.05
9302526 44.93 42.68 49.08
93025 TC 209.08 198.63 228.42
93304 157.98 150.08 172.59
9330426 42.44 40.32 46.37
9258826 19.55 18.57 21.36 93040 14.98 14.23 16.36 93304TC 115.55 109.77 126.24
92588 TC 52.81 50.17 57.70
92596 41.06 39.01 44.86
93041 6.48 6.16 7.08
93042 8.51 8.08 9.29
93306 313.58 297.90 342.59
9330626 78.69 74.76 85.97
92597 116.66 110.83 127.45
# 92597 48.18 45.77 52.64
93224 139.15 132.19 152.02
93225 42.53 40.40 46.46
93306TC 234.90 223.16 256.63
93307 206.88 196.54 226.02
92601 169.68 161.20 185.38 93226 65.47 62.20 71.53 9330726 54.41 51.69 59.44
# 92601 153.77 146.08 167.99
92602 106.95 101.60 116.84
93227 31.15 29.59 34.03
93228 27.61 26.23 30.16
93307TC 152.47 144.85 166.58
93308 131.17 124.61 143.30
# 92602 92.37 87.75 100.91
92603 151.45 143.88 165.46
93230 142.38 135.26 155.55
93231 42.51 40.38 46.44
9330826 31.97 30.37 34.93
93308TC 99.20 94.24 108.38
# 92603 136.87 130.03 149.53
92604 90.49 85.97 98.87
93232 70.04 66.54 76.52
93233 29.82 28.33 32.58
93312 378.74 359.80 413.77
9331226 126.45 120.13 138.15
# 92604 78.56 74.63 85.82 93235 148.11 140.70 161.81 93312 TC 252.29 239.68 275.63
92607 183.48 174.31 200.46
92608 35.03 33.28 38.27
93236 122.21 116.10 133.52
93237 26.75 25.41 29.22
93313 43.59 41.41 47.62
93314 329.98 313.48 360.50
92609 97.48 92.61 106.50
92610 94.22 89.51 102.94
93268 317.47 301.60 346.84
93270 25.29 24.03 27.63
9331426 71.51 67.93 78.12
93314TC 258.48 245.56 282.39
92611 102.61 97.48 112.10 93271 262.36 249.24 286.63 93315 328.16 311.75 358.51
92612 176.53 167.70 192.86
# 92612 70.93 67.38 77.49
93272 29.82 28.33 32.58
93278 46.44 44.12 50.74
9331526 162.21 154.10 177.22
93315TC 166.28 157.97 181.67
92613 40.92 38.87 44.70
92614 156.20 148.39 170.65
9327826 14.09 13.39 15.40
93278 TC 32.35 30.73 35.34
93316 48.61 46.18 53.11
93317 273.15 259.49 298.41
# 92614 70.93 67.38 77.49
92615 36.59 34.76 39.97
93279 63.26 60.10 69.12
9327926 39.56 37.58 43.22
9331726 99.75 94.76 108.97
93317TC 166.28 157.97 181.67
92616 213.71 203.02 233.47 93279 TC 23.69 22.51 25.89 9331826 121.56 115.48 132.80
# 92616 104.58 99.35 114.25
92617 44.81 42.57 48.96
93280 74.98 71.23 81.91
9328026 47.60 45.22 52.00
93320 91.38 86.81 99.83
9332026 22.51 21.38 24.59
CODES: 92542TC - 9332026
# - These amounts apply when the service is performed in a facility setting.
C - The payment for the technical component is capped at the OPPS amount.
Limiting charge applies to unassigned claims by non-participating providers. All CPT codes and modifiers are bolded.
All Current Procedural Terminology (CPT) codes and descriptors are copyrighted 2008 by the American Medical Association..

93320TC
93321
9332126
93321TC
93325
9332526
93325TC
93350
9335026
93350TC
93351
93352
93501
9350126
93501TC
93503
93505
9350526
93505TC
93508
9350826
93508TC
93510
9351026
93510TC
93511
9351126
93511TC
93514
9351426
93514TC
93524
9352426
93524TC
93526
9352626
93526TC
93527
9352726
93527TC
93528
9352826
93528TC
93529
9352926
93529TC
93530
9353026
93530TC
93531
9353126
93531TC
93532
9353226
93532TC
93533
9353326
93533TC
93539
93539
93540
93540
93541
93542
93542
93543
93543
93544
93544
93545
93545
93555
9355526
93555TC
93556
9355626
93556TC
93561
9356126
93561TC
93562
9356226
93562TC
93571
9357126
93571TC
93572
9357226
93572TC
93580
93581
93600
9360026
93600TC
93602
9360226
93602TC
93603
9360326
93603TC
93609
9360926
93609TC
93610
9361026
93610TC
93612
9361226
93612TC
93613
93615
9361526
93615TC
93616
9361626
93616TC
93618
9361826
93618TC
93619
9361926
93619TC
9362026
9362126
9362226
9362326
93624
9362426
93624TC
93631
9363126
93631TC
93640
9364026
93640TC
93641
9364126
93641TC
93642
9364226
93642TC
93650
93651
93652
93660
9366026
93660TC
9366226
93701
9370126
93701TC
93720
93721
93722
93724
9372426
93724TC
93745
9374526
93745TC
93784
93786
93788
93790
93797
93797
93798
93798
93875
9387526
93875TC
93880
9388026
93880TC
93882
9388226
93882TC
93886
9388626
93886TC
93888
9388826
93888TC
93890
9389026
93890TC
93892
9389226
93892TC
93893
9389326
93893TC
93922
9392226
93922TC
93923
9392326
93923TC
93924
9392426
93924TC
93925
9392526
93925TC
93926
9392626
93926TC
93930
9393026
93930TC
93931
9393126
93931TC
93965
9396526
93965TC
93970
9397026
93970TC
93971
9397126
93971TC
93975
9397526
93975TC
93976
9397626
93976TC
93978
9397826
93978TC






California - MEDICARE CARRIER 01192 FSY2009 LOCALITY 18 FEE SCHEDULE PAGE: 43
PROCEDURE PAR NONPAR LIMITING
CODE/MOD FEE FEE CHARGE
PROCEDURE PAR NONPAR LIMITING
CODE/MOD FEE FEE CHARGE
PROCEDURE PAR NONPAR LIMITING
CODE/MOD FEE FEE CHARGE
93320 TC 68.87 65.43 75.24
93321 40.49 38.47 44.24
93561 53.25 50.59 58.18
9356126 25.54 24.26 27.90
93724 371.70 353.12 406.09
9372426 292.72 278.08 319.79
9332126 9.01 8.56 9.84 93561 TC 25.35 24.08 27.69 93724 TC 78.98 75.03 86.28
93321 TC 31.48 29.91 34.40
93325 62.47 59.35 68.25
93562 24.72 23.48 27.00
9356226 8.06 7.66 8.81
93745 150.76 143.22 164.70
9374526 104.17 98.96 113.80
9332526 4.24 4.03 4.63
93325 TC 58.22 55.31 63.61
93562 TC 15.72 14.93 17.17
93571 316.87 301.03 346.18
93745TC 46.60 44.27 50.91
93784 76.99 73.14 84.11
93350 246.92 234.57 269.76 9357126 108.64 103.21 118.69 93786 36.08 34.28 39.42
9335026 88.08 83.68 96.23
93350 TC 158.85 150.91 173.55
93571 TC 212.24 201.63 231.87
93572 188.01 178.61 205.40
93788 20.17 19.16 22.03
93790 20.74 19.70 22.66
93351 322.69 306.56 352.54
93352 45.41 43.14 49.61
9357226 85.27 81.01 93.16
93572 TC 105.91 100.61 115.70
93797 20.74 19.70 22.66
# 93797 10.58 10.05 11.56
93501 945.48 898.21 1,032.94
9350126 184.87 175.63 201.97
93580 1,109.90 1,054.41 1,212.57
93581 1,446.74 1,374.40 1,580.56
93798 29.80 28.31 32.56
# 93798 16.55 15.72 18.08
93501 TC 760.62 722.59 830.98 93600 219.82 208.83 240.15 93875 120.87 114.83 132.05
93503 115.06 109.31 125.71
93505 878.57 834.64 959.84
9360026 129.74 123.25 141.74
93600 TC 92.02 87.42 100.53
9387526 12.08 11.48 13.20
93875 TC 108.78 103.34 118.84
9350526 267.32 253.95 292.04
93505 TC 611.25 580.69 667.79
93602 179.71 170.72 196.33
9360226 129.15 122.69 141.09
C 93880 217.38 206.51 237.49
9388026 33.41 31.74 36.50
93508 1,258.12 1,195.21 1,374.49 93602 TC 51.99 49.39 56.80 C 93880TC 183.98 174.78 201.00
9350826 257.55 244.67 281.37
93508 TC 1,000.56 950.53 1,093.11
93603 206.48 196.16 225.58
9360326 129.44 122.97 141.42
93882 193.98 184.28 211.92
9388226 21.92 20.82 23.94
93510 1,565.54 1,487.26 1,710.35
9351026 271.63 258.05 296.76
93603 TC 78.83 74.89 86.12
93609 427.90 406.51 467.49
93882TC 172.06 163.46 187.98
C 93886 234.86 223.12 256.59
93510 TC 1,293.91 1,229.21 1,413.59
93511 2,011.01 1,910.46 2,197.03
9360926 306.19 290.88 334.51
93609 TC 127.77 121.38 139.59
9388626 50.73 48.19 55.42
C 93886TC 184.13 174.92 201.16
9351126 314.82 299.08 343.94 93610 245.28 233.02 267.97 C 93888 109.36 103.89 119.47
93511 TC 1,687.86 1,603.47 1,843.99
93514 2,110.75 2,005.21 2,305.99
9361026 183.53 174.35 200.50
93610 TC 63.76 60.57 69.66
9388826 34.45 32.73 37.64
C 93888TC 74.92 71.17 81.85
9351426 432.28 410.67 472.27
93514 TC 1,670.58 1,587.05 1,825.11
93612 257.58 244.70 281.41
9361226 182.49 173.37 199.38
C 93890 170.86 162.32 186.67
9389026 53.87 51.18 58.86
93524 2,644.08 2,511.88 2,888.66 93612 TC 75.70 71.92 82.71 C 93890 TC 117.00 111.15 127.82
9352426 433.98 412.28 474.12
93524 TC 2,206.71 2,096.37 2,410.83
93613 430.40 408.88 470.21
93615 67.78 64.39 74.05
C 93892 178.41 169.49 194.91
9389226 61.26 58.20 66.93
93526 2,004.64 1,904.41 2,190.07
9352626 374.10 355.40 408.71
9361526 58.81 55.87 64.25
93615 TC 14.97 14.22 16.35
C 93892 TC 117.15 111.29 127.98
C 93893 178.86 169.92 195.41
93526 TC 1,630.53 1,549.00 1,781.35
93527 2,664.63 2,531.40 2,911.11
93616 97.35 92.48 106.35
9361626 74.02 70.32 80.87
9389326 61.71 58.62 67.41
C 93893TC 117.15 111.29 127.98
9352726 452.98 430.33 494.88 93616 TC 14.86 14.12 16.24 93922 143.63 136.45 156.92
93527 TC 2,206.71 2,096.37 2,410.83
93528 2,769.67 2,631.19 3,025.87
93618 441.25 419.19 482.07
9361826 263.26 250.10 287.62
9392226 13.50 12.83 14.75
93922 TC 130.13 123.62 142.16
9352826 535.33 508.56 584.84
93528 TC 2,206.71 2,096.37 2,410.83
93618 TC 185.53 176.25 202.69
93619 814.65 773.92 890.01
93923 221.04 209.99 241.49
9392326 24.68 23.45 26.97
93529 2,512.31 2,386.69 2,744.69 9361926 454.93 432.18 497.01 93923 TC 196.36 186.54 214.52
9352926 300.31 285.29 328.08
93529 TC 2,206.71 2,096.37 2,410.83
93619 TC 360.91 342.86 394.29
9362026 714.29 678.58 780.37
93924 272.68 259.05 297.91
9392426 28.18 26.77 30.79
93530 1,059.22 1,006.26 1,157.20
9353026 254.77 242.03 278.33
9362126 129.14 122.68 141.08
9362226 188.60 179.17 206.05
93924 TC 244.50 232.28 267.12
C 93925 216.22 205.41 236.22
93530 TC 793.06 753.41 866.42
93531 2,782.84 2,643.70 3,040.26
9362326 175.10 166.35 191.30
93624 395.82 376.03 432.43
9392526 31.77 30.18 34.71
C 93925TC 184.44 175.22 201.50
9353126 498.28 473.37 544.38 9362426 298.92 283.97 326.57 C 93926 139.30 132.34 152.19
93531 TC 2,267.43 2,154.06 2,477.17
93532 2,800.03 2,660.03 3,059.03
93624 TC 93.36 88.69 101.99
93631 755.28 717.52 825.15
9392626 21.55 20.47 23.54
C 93926TC 117.76 111.87 128.65
9353226 589.93 560.43 644.49
93532 TC 2,183.45 2,074.28 2,385.42
9363126 435.04 413.29 475.28
93631 TC 294.40 279.68 321.63
C 93930 209.32 198.85 228.68
9393026 25.50 24.23 27.86
93533 2,593.79 2,464.10 2,833.72 93640 545.53 518.25 595.99 C 93930TC 183.82 174.63 200.82
9353326 397.35 377.48 434.10
93533 TC 2,183.45 2,074.28 2,385.42
9364026 214.74 204.00 234.60
93640 TC 335.48 318.71 366.52
C 93931 134.23 127.52 146.65
9393126 16.93 16.08 18.49
93539 95.28 90.52 104.10
# 93539 24.14 22.93 26.37
93641 691.11 656.55 755.03
9364126 363.61 345.43 397.24
C 93931TC 117.30 111.44 128.16
93965 146.21 138.90 159.74
93540 289.48 275.01 316.26
# 93540 26.15 24.84 28.57
93641 TC 335.48 318.71 366.52
93642 538.18 511.27 587.96
9396526 19.02 18.07 20.78
93965TC 127.19 120.83 138.95
93541 17.36 16.49 18.96 9364226 298.47 283.55 326.08 C 93970 220.95 209.90 241.39
93542 175.53 166.75 191.76
# 93542 17.36 16.49 18.96
93642 TC 239.71 227.72 261.88
93650 656.69 623.86 717.44
9397026 37.43 35.56 40.89
C 93970TC 183.52 174.34 200.49
93543 95.12 90.36 103.91
# 93543 17.36 16.49 18.96
93651 996.91 947.06 1,089.12
93652 1,084.93 1,030.68 1,185.28
C 93971 141.83 134.74 154.95
9397126 24.83 23.59 27.13
93544 68.88 65.44 75.26 93660 196.11 186.30 214.25 C 93971TC 117.00 111.15 127.82
# 93544 15.42 14.65 16.85
93545 201.75 191.66 220.41
9366026 113.79 108.10 124.32
93660 TC 82.32 78.20 89.93
C 93975 284.35 270.13 310.65
9397526 100.07 95.07 109.33
# 93545 24.14 22.93 26.37
93555 133.48 126.81 145.83
9366226 168.71 160.27 184.31
93701 40.10 38.10 43.82
C 93975TC 184.28 175.07 201.33
C 93976 249.25 236.79 272.31
9355526 48.95 46.50 53.48
93555 TC 84.53 80.30 92.35
9370126 9.77 9.28 10.67
93701 TC 30.33 28.81 33.13
9397626 66.32 63.00 72.45
C 93976TC 182.93 173.78 199.85
93556 188.20 178.79 205.61 93720 54.36 51.64 59.39 C 93978 219.38 208.41 239.67
9355626 50.15 47.64 54.79
93556 TC 138.06 131.16 150.83
93721 45.48 43.21 49.69
93722 8.88 8.44 9.71
9397826 35.86 34.07 39.18
C 93978 TC 183.52 174.34 200.49
CODES: 93320TC - 93978TC
# - These amounts apply when the service is performed in a facility setting.
C - The payment for the technical component is capped at the OPPS amount.
Limiting charge applies to unassigned claims by non-participating providers. All CPT codes and modifiers are bolded.
All Current Procedural Terminology (CPT) codes and descriptors are copyrighted 2008 by the American Medical Association.

93979
9397926
93979TC
93980
9398026
93980TC
93981
9398126
93981TC
93982
93990
9399026
93990TC
94002
94003
94004
94010
9401026
94010TC
94014
94015
94016
94060
9406026
94060TC
94070
9407026
94070TC
94200
9420026
94200TC
94240
9424026
94240TC
94250
9425026
94250TC
94260
9426026
94260TC
94350
9435026
94350TC
94360
9436026
94360TC
94370
9437026
94370TC
94375
9437526
94375TC
94400
9440026
94400TC
94450
9445026
94450TC
94452
9445226
94452TC
94453
9445326
94453TC
94610
94620
9462026
94620TC
94621
9462126
94621TC
94640
94642
94644
94645
94660
94660
94662
94664
94667
94668
94680
9468026
94680TC
94681
9468126
94681TC
94690
9469026
94690TC
94720
9472026
94720TC
94725
9472526
94725TC
94750
9475026
94750TC
94760
94761
94762
94770
9477026
94770TC
95004
95010
95012
95015
95024
95027
95028
95044
95052
95056
95060
95065
95070
95071
95075
95075
95115
95117
95144
95144
95145
95145
95146
95146
95147
95147
95148
95148
95149
95149
95165
95165
95170
95170
95180
95180
95250
95251
95805
9580526
95805TC
95806
9580626
95806TC
95807
9580726
95807TC
95808
9580826
95808TC
95810
9581026
95810TC
95811
9581126
95811TC
95812
9581226
95812TC
95813
9581326
95813TC
95816
9581626
95816TC
95819
9581926
95819TC
95822
9582226
95822TC
9582426
95827
9582726
95827TC
95829
9582926
95829TC
95830
95830
95831
95831
95832
95832
95833
95833
95834
95834
95851
95851
95852
95852
95857
95857
95860
9586026
95860TC
95861
9586126
95861TC
95863
9586326
95863TC
95864
9586426
95864TC
95865
9586526
95865TC
95866
9586626
95866TC
95867
9586726
95867TC
95868
9586826
95868TC
95869
9586926
95869TC
95870
9587026
95870TC
95872
9587226






California - MEDICARE CARRIER 01192 FSY2009 LOCALITY 18 FEE SCHEDULE PAGE: 44
PROCEDURE PAR NONPAR CHARGE
CODE/MOD FEE FEE LIMIT
PROCEDURE PAR NONPAR CHARGE
CODE/MOD FEE FEE LIMIT
PROCEDURE PAR NONPAR CHARGE
CODE/MOD FEE FEE LIMIT
C 93979 141.32 134.25 154.39
9397926 24.02 22.82 26.24
94662 38.24 36.33 41.78
94664 17.51 16.63 19.12
95808TC 626.74 595.40 684.71
95810 907.87 862.48 991.85
C 93979 TC 117.30 111.44 128.16 94667 24.42 23.20 26.68 9581026 181.27 172.21 198.04
93980 211.98 201.38 231.59
9398026 70.90 67.36 77.46
94668 23.11 21.95 25.24
94680 67.46 64.09 73.70
95810TC 726.60 690.27 793.81
95811 1,001.20 951.14 1,093.81
93980 TC 141.08 134.03 154.13
93981 151.56 143.98 165.58
9468026 13.14 12.48 14.35
94680 TC 54.32 51.60 59.34
9581126 194.79 185.05 212.81
95811TC 806.41 766.09 881.00
9398126 24.17 22.96 26.40 94681 73.57 69.89 80.37 95812 278.32 264.40 304.06
93981 TC 127.40 121.03 139.18
93982 46.46 44.14 50.76
9468126 10.01 9.51 10.94
94681 TC 63.57 60.39 69.45
9581226 57.75 54.86 63.09
95812TC 220.56 209.53 240.96
C 93990 131.26 124.70 143.41
9399026 13.35 12.68 14.58
94690 60.19 57.18 65.76
9469026 3.80 3.61 4.15
95813 338.49 321.57 369.81
9581326 91.86 87.27 100.36
C 93990 TC 117.91 112.01 128.81
94002 92.79 88.15 101.37
94690 TC 56.39 53.57 61.61
94720 59.95 56.95 65.49
95813TC 246.63 234.30 269.45
95816 254.61 241.88 278.16
94003 67.76 64.37 74.03 9472026 13.14 12.48 14.35 9581626 57.75 54.86 63.09
94004 49.31 46.84 53.87
94010 38.62 36.69 42.19
94720 TC 46.81 44.47 51.14
94725 78.04 74.14 85.26
95816TC 196.86 187.02 215.07
95819 274.05 260.35 299.40
9401026 8.88 8.44 9.71
94010 TC 29.74 28.25 32.49
9472526 13.14 12.48 14.35
94725 TC 64.89 61.65 70.90
9581926 57.75 54.86 63.09
95819TC 216.30 205.49 236.31
94014 55.30 52.54 60.42 94750 83.87 79.68 91.63 95822 272.71 259.07 297.93
94015 28.57 27.14 31.21
94016 26.73 25.39 29.20
9475026 11.58 11.00 12.65
94750 TC 72.29 68.68 78.98
9582226 57.75 54.86 63.09
95822TC 214.96 204.21 234.84
94060 67.57 64.19 73.82
9406026 15.46 14.69 16.89
94760 3.23 3.07 3.53
94761 6.16 5.85 6.73
9582426 39.55 37.57 43.21
95827 446.34 424.02 487.62
94060 TC 52.11 49.50 56.93
94070 67.83 64.44 74.11
94762 34.71 32.97 37.92
94770 42.41 40.29 46.33
9582726 57.02 54.17 62.30
95827TC 389.32 369.85 425.33
9407026 30.47 28.95 33.29 9477026 7.69 7.31 8.41 95829 1,418.09 1,347.19 1,549.27
94070 TC 37.36 35.49 40.81
94200 26.21 24.90 28.64
94770 TC 34.72 32.98 37.93
95004 6.85 6.51 7.49
9582926 335.50 318.73 366.54
95829TC 1,082.59 1,028.46 1,182.73
9420026 5.75 5.46 6.28
94200 TC 20.46 19.44 22.36
95010 19.62 18.64 21.44
95012 23.71 22.52 25.90
95830 200.45 190.43 218.99
# 95830 90.87 86.33 99.28
94240 45.08 42.83 49.25 95015 14.32 13.60 15.64 95831 28.92 27.47 31.59
9424026 13.14 12.48 14.35
94240 TC 31.94 30.34 34.89
95024 8.18 7.77 8.94
95027 5.53 5.25 6.04
# 95831 15.22 14.46 16.63
95832 26.93 25.58 29.42
94250 28.57 27.14 31.21
9425026 5.75 5.46 6.28
95028 13.10 12.45 14.32
95044 7.36 6.99 8.04
# 95832 15.89 15.10 17.37
95833 39.43 37.46 43.08
94250 TC 22.82 21.68 24.93
94260 36.82 34.98 40.23
95052 8.24 7.83 9.00
95056 41.82 39.73 45.69
# 95833 25.30 24.04 27.65
95834 46.37 44.05 50.66
9426026 6.50 6.18 7.11 95060 27.97 26.57 30.56 # 95834 31.79 30.20 34.73
94260 TC 30.32 28.80 33.12
94350 39.93 37.93 43.62
95065 25.47 24.20 27.83
95070 51.83 49.24 56.63
95851 18.67 17.74 20.40
# 95851 8.51 8.08 9.29
9435026 13.14 12.48 14.35
94350 TC 26.79 25.45 29.27
95071 64.20 60.99 70.14
95075 69.23 65.77 75.64
95852 14.58 13.85 15.93
# 95852 6.19 5.88 6.76
94360 50.23 47.72 54.88 # 95075 50.68 48.15 55.37 95857 46.10 43.80 50.37
9436026 13.14 12.48 14.35
94360 TC 37.09 35.24 40.53
95115 12.51 11.88 13.66
95117 15.16 14.40 16.56
# 95857 28.87 27.43 31.54
95860 91.09 86.54 99.52
94370 38.47 36.55 42.03
9437026 13.14 12.48 14.35
95144 13.59 12.91 14.85
# 95144 3.43 3.26 3.75
9586026 52.96 50.31 57.86
95860 TC 38.13 36.22 41.65
94370 TC 25.32 24.05 27.66
94375 42.55 40.42 46.48
95145 18.01 17.11 19.68
# 95145 3.43 3.26 3.75
95861 130.95 124.40 143.06
9586126 84.59 80.36 92.41
9437526 15.46 14.69 16.89 95146 29.94 28.44 32.71 95861TC 46.36 44.04 50.65
94375 TC 27.09 25.74 29.60
94400 60.48 57.46 66.08
# 95146 3.43 3.26 3.75
95147 29.05 27.60 31.74
95863 155.85 148.06 170.27
9586326 101.10 96.05 110.46
9440026 20.75 19.71 22.67
94400 TC 39.74 37.75 43.41
# 95147 3.43 3.26 3.75
95148 40.98 38.93 44.77
95863TC 54.76 52.02 59.82
95864 179.77 170.78 196.40
94450 58.15 55.24 63.53 # 95148 3.43 3.26 3.75 9586426 108.25 102.84 118.27
9445026 20.02 19.02 21.87
94450 TC 38.13 36.22 41.65
95149 53.79 51.10 58.77
# 95149 3.43 3.26 3.75
95864TC 71.52 67.94 78.13
95865 124.87 118.63 136.42
94452 64.93 61.68 70.93
9445226 15.75 14.96 17.20
95165 13.59 12.91 14.85
# 95165 3.43 3.26 3.75
9586526 87.33 82.96 95.40
95865TC 37.54 35.66 41.01
94452 TC 49.18 46.72 53.73
94453 86.87 82.53 94.91
95170 10.50 9.98 11.48
# 95170 3.43 3.26 3.75
95866 102.41 97.29 111.88
9586626 69.29 65.83 75.70
9445326 20.46 19.44 22.36 95180 156.15 148.34 170.59 95866TC 33.12 31.46 36.18
94453 TC 66.41 63.09 72.55
94610 67.44 64.07 73.68
# 95180 114.62 108.89 125.22
95250 157.13 149.27 171.66
95867 79.41 75.44 86.76
9586726 42.90 40.76 46.87
94620 81.70 77.62 89.26
9462026 32.85 31.21 35.89
95251 42.66 40.53 46.61
95805 497.48 472.61 543.50
95867TC 36.51 34.68 39.88
95868 108.17 102.76 118.17
94620 TC 48.85 46.41 53.37 9580526 97.94 93.04 107.00 9586826 63.87 60.68 69.78
94621 185.20 175.94 202.33
9462126 75.82 72.03 82.83
95805 TC 399.54 379.56 436.49
95806 239.32 227.35 261.45
95868TC 44.31 42.09 48.40
95869 51.72 49.13 56.50
94621 TC 109.38 103.91 119.50
94640 16.04 15.24 17.53
9580626 86.74 82.40 94.76
95806 TC 152.58 144.95 166.69
9586926 20.22 19.21 22.09
95869TC 31.51 29.93 34.42
94642 38.69 36.76 42.27
94644 41.23 39.17 45.05
95807 585.80 556.51 639.99
9580726 85.85 81.56 93.79
95870 50.40 47.88 55.06
9587026 20.22 19.21 22.09
94645 16.04 15.24 17.53 95807 TC 499.94 474.94 546.18 95870 TC 30.18 28.67 32.97
94660 62.83 59.69 68.64
# 94660 38.53 36.60 42.09
95808 764.47 726.25 835.19
9580826 137.73 130.84 150.47
95872 179.94 170.94 196.58
9587226 148.00 140.60 161.69
CODES: 93979 - 9587226
# - These amounts apply when the service is performed in a facility setting.
C - The payment for the technical component is capped at the OPPS amount.
Limiting charge applies to unassigned claims by non-participating providers. All CPT codes and modifiers are bolded.
All Current Procedural Terminology (CPT) codes and descriptors are copyrighted 2008 by the American Medical Association..

95872TC
95873
9587326
95873TC
95874
9587426
95874TC
95875
9587526
95875TC
95900
9590026
95900TC
95903
9590326
95903TC
95904
9590426
95904TC
95920
9592026
95920TC
95921
9592126
95921TC
95922
9592226
95922TC
95923
9592326
95923TC
95925
9592526
95925TC
95926
9592626
95926TC
95927
9592726
95927TC
95928
9592826
95928TC
95929
9592926
95929TC
95930
9593026
95930TC
95933
9593326
95933TC
95934
9593426
95934TC
95936
9593626
95936TC
95937
9593726
95937TC
95950
9595026
95950TC
95951
9595126
95951TC
95953
9595326
95953TC
95954
9595426
95954TC
95955
9595526
95955TC
95956
9595626
95956TC
95957
9595726
95957TC
95958
9595826
95958TC
95961
9596126
95961TC
95962
9596226
95962TC
95965
9596526
95965TC
95966
9596626
95966TC
95967
9596726
95967TC
95970
95970
95971
95971
95972
95972
95973
95973
95974
95974
95975
95975
95978
95978
95979
95979
95980
95981
95981
95982
95982
95990
95991
95991
96000
96001
96002
96003
96004
9602026
96101
96101
96102
96102
96103
96103
96105
96110
96111
96111
96116
96116
96118
96118
96119
96119
96120
96120
96125
96125
96150
96150
96151
96151
96152
96152
96153
96153
96154
96154
96360
96361
96365
96366
96367
96368
96369
96370
96371
96372
96373
96374
96375
96401
96402
96405
96405
96406
96406
96409
96411
96413
96415
96416
96417
96420
96422
96423
96425
96440
96440
96445
96445
96450
96450
96521
96522
96523
96542
96542
96567
96570
96571
96900
96904
96910
96912
96913
96920
96920
96921
96921
96922
96922
97001
97002
97003
97004
97012
97016
97018
97022
97024
97026
97028
97032
97033
97034
97035
97036
97110






California - MEDICARE CARRIER 01192 FSY2009 LOCALITY 18 FEE SCHEDULE PAGE: 45
PROCEDURE PAR NONPAR LIMITING
CODE/MOD FEE FEE CHARGE
PROCEDURE PAR NONPAR LIMITING
CODE/MOD FEE FEE CHARGE
PROCEDURE PAR NONPAR LIMITING
CODE/MOD FEE FEE CHARGE
95872 TC 31.94 30.34 34.89
95873 52.61 49.98 57.48
9595626 164.90 156.66 180.16
95956 TC 663.71 630.52 725.10
96152 22.42 21.30 24.50
# 96152 21.98 20.88 24.01
9587326 21.54 20.46 23.53 95957 297.50 282.63 325.02 96153 5.37 5.10 5.87
95873 TC 31.07 29.52 33.95
95874 49.51 47.03 54.08
9595726 106.25 100.94 116.08
95957 TC 191.25 181.69 208.94
# 96153 4.93 4.68 5.38
96154 22.05 20.95 24.09
9587426 20.66 19.63 22.57
95874 TC 28.86 27.42 31.53
95958 429.28 407.82 468.99
9595826 227.14 215.78 248.15
# 96154 21.60 20.52 23.60
96360 67.17 63.81 73.38
95875 103.69 98.51 113.29 95958 TC 202.14 192.03 220.83 96361 19.12 18.16 20.88
9587526 59.10 56.15 64.57
95875 TC 44.60 42.37 48.73
95961 255.58 242.80 279.22
9596126 170.49 161.97 186.27
96365 81.93 77.83 89.50
96366 25.15 23.89 27.47
95900 60.67 57.64 66.29
9590026 22.98 21.83 25.10
95961 TC 85.09 80.84 92.97
95962 233.01 221.36 254.56
96367 40.55 38.52 44.30
96368 23.45 22.28 25.62
95900 TC 37.69 35.81 41.18
95903 70.37 66.85 76.88
9596226 176.19 167.38 192.49
95962 TC 56.81 53.97 62.07
96369 181.05 172.00 197.80
96370 17.64 16.76 19.27
9590326 32.23 30.62 35.21 95965 2,127.45 2,021.08 2,324.24 96371 88.65 84.22 96.85
95903 TC 38.13 36.22 41.65
95904 53.69 51.01 58.66
9596526 439.69 417.71 480.37
95965 TC 1,654.89 1,572.15 1,807.97
96372 24.35 23.13 26.60
96373 20.66 19.63 22.57
9590426 18.65 17.72 20.38
95904 TC 35.04 33.29 38.28
95966 1,836.38 1,744.56 2,006.24
9596626 218.94 207.99 239.19
96374 64.91 61.66 70.91
96375 27.89 26.50 30.48
95920 166.30 157.99 181.69 95966 TC 1,607.89 1,527.50 1,756.63 96401 81.07 77.02 88.57
9592026 115.23 109.47 125.89
95920 TC 51.07 48.52 55.80
95967 1,808.25 1,717.84 1,975.52
9596726 186.92 177.57 204.21
96402 43.65 41.47 47.69
96405 99.48 94.51 108.69
95921 81.92 77.82 89.49
9592126 47.76 45.37 52.18
95967 TC 1,607.89 1,527.50 1,756.63
95970 56.65 53.82 61.89
# 96405 31.44 29.87 34.35
96406 136.94 130.09 149.60
95921 TC 34.16 32.45 37.32
95922 99.04 94.09 108.20
# 95970 23.51 22.33 25.68
95971 63.13 59.97 68.97
# 96406 45.49 43.22 49.70
96409 134.46 127.74 146.90
9592226 51.19 48.63 55.92 # 95971 42.80 40.66 46.76 96411 75.96 72.16 82.98
95922 TC 47.85 45.46 52.28
95923 132.58 125.95 144.84
95972 111.63 106.05 121.96
# 95972 81.14 77.08 88.64
96413 177.63 168.75 194.06
96415 38.77 36.83 42.35
9592326 48.50 46.08 52.99
95923 TC 84.08 79.88 91.86
95973 60.43 57.41 66.02
# 95973 48.06 45.66 52.51
96416 194.44 184.72 212.43
96417 87.67 83.29 95.78
95925 137.16 130.30 149.85 95974 184.43 175.21 201.49 96420 129.76 123.27 141.76
9592526 29.39 27.92 32.11
95925 TC 107.78 102.39 117.75
# 95974 158.81 150.87 173.50
95975 101.77 96.68 111.18
96422 210.61 200.08 230.09
96423 93.56 88.88 102.21
95926 134.66 127.93 147.12
9592626 29.10 27.65 31.80
# 95975 91.61 87.03 100.08
95978 219.69 208.71 240.02
96425 207.52 197.14 226.71
96440 714.22 678.51 780.29
95926 TC 105.57 100.29 115.33
95927 138.05 131.15 150.82
# 95978 186.55 177.22 203.80
95979 97.91 93.01 106.96
# 96440 143.84 136.65 157.15
96445 332.75 316.11 363.53
9592726 29.83 28.34 32.59 # 95979 87.75 83.36 95.86 # 96445 126.42 120.10 138.12
95927 TC 108.22 102.81 118.23
95928 215.33 204.56 235.24
95980 43.11 40.95 47.09
95981 31.28 29.72 34.18
96450 243.41 231.24 265.93
# 96450 96.28 91.47 105.19
9592826 79.71 75.72 87.08
95928 TC 135.62 128.84 148.17
# 95981 17.15 16.29 18.73
95982 47.50 45.13 51.90
96521 153.21 145.55 167.38
96522 129.80 123.31 141.81
95929 227.70 216.32 248.77 # 95982 34.69 32.96 37.90 96523 30.51 28.98 33.33
9592926 80.15 76.14 87.56
95929 TC 147.55 140.17 161.20
95990 70.66 67.13 77.20
95991 100.01 95.01 109.26
96542 158.32 150.40 172.96
# 96542 49.63 47.15 54.22
95930 122.70 116.57 134.06
9593026 19.02 18.07 20.78
# 95991 38.60 36.67 42.17
96000 92.42 87.80 100.97
96567 142.54 135.41 155.72
96570 62.16 59.05 67.91
95930 TC 103.67 98.49 113.26
95933 72.33 68.71 79.02
96001 109.25 103.79 119.36
96002 21.72 20.63 23.72
96571 29.91 28.41 32.67
96900 23.55 22.37 25.73
9593326 32.15 30.54 35.12 96003 18.89 17.95 20.64 96904 78.49 74.57 85.76
95933 TC 40.18 38.17 43.90
95934 53.89 51.20 58.88
96004 118.44 112.52 129.40
9602026 192.47 182.85 210.28
96910 76.27 72.46 83.33
96912 97.77 92.88 106.81
9593426 27.68 26.30 30.25
95934 TC 26.21 24.90 28.64
96101 90.28 85.77 98.64
# 96101 89.84 85.35 98.15
96913 135.44 128.67 147.97
96920 188.23 178.82 205.64
95936 46.84 44.50 51.18 96102 59.27 56.31 64.76 # 96920 69.82 66.33 76.28
9593626 29.91 28.41 32.67
95936 TC 16.93 16.08 18.49
# 96102 24.36 23.14 26.61
96103 52.86 50.22 57.75
96921 183.97 174.77 200.99
# 96921 69.10 65.65 75.50
95937 63.53 60.35 69.40
9593726 36.44 34.62 39.81
# 96103 25.47 24.20 27.83
96105 87.40 83.03 95.48
96922 269.99 256.49 294.96
# 96922 123.30 117.14 134.71
95937 TC 27.09 25.74 29.60
95950 272.95 259.30 298.20
96110 13.17 12.51 14.39
96111 139.51 132.53 152.41
97001 76.99 73.14 84.11
97002 41.66 39.58 45.52
9595026 80.66 76.63 88.12 # 96111 135.97 129.17 148.55 97003 82.14 78.03 89.73
95950 TC 192.29 182.68 210.08
95951 2,003.11 1,902.95 2,188.39
96116 102.00 96.90 111.44
# 96116 95.82 91.03 104.68
97004 48.29 45.88 52.76
97012 15.86 15.07 17.33
9595126 320.77 304.73 350.44
95951 TC 1,636.73 1,554.89 1,788.12
96118 117.47 111.60 128.34
# 96118 93.17 88.51 101.79
97016 17.21 16.35 18.80
97018 9.17 8.71 10.02
95953 457.64 434.76 499.97 96119 84.63 80.40 92.46 97022 19.93 18.93 21.77
9595326 175.22 166.46 191.43
95953 TC 282.42 268.30 308.55
# 96119 31.61 30.03 34.53
96120 80.26 76.25 87.69
97024 6.08 5.78 6.65
97026 5.64 5.36 6.16
95954 279.08 265.13 304.90
9595426 120.50 114.48 131.65
# 96120 25.47 24.20 27.83
96125 102.49 97.37 111.98
97028 6.83 6.49 7.46
97032 18.07 17.17 19.75
95954 TC 158.58 150.65 173.25
95955 157.41 149.54 171.97
# 96125 85.26 81.00 93.15
96150 24.36 23.14 26.61
97033 27.72 26.33 30.28
97034 16.57 15.74 18.10
9595526 53.07 50.42 57.98 # 96150 23.92 22.72 26.13 97035 12.59 11.96 13.75
95955 TC 104.34 99.12 113.99
95956 828.61 787.18 905.26
96151 23.61 22.43 25.79
# 96151 23.17 22.01 25.31
97036 28.92 27.47 31.59
97110 31.17 29.61 34.05
CODES: 95872TC - 97110
# - These amounts apply when the service is performed in a facility setting.
C - The payment for the technical component is capped at the OPPS amount.
Limiting charge applies to unassigned claims by non-participating providers. All CPT codes and modifiers are bolded.
All Current Procedural Terminology (CPT) codes and descriptors are copyrighted 2008 by the American Medical Association.

97112
97113
97116
97124
97140
97150
97530
97532
97533
97535
97537
97542
97597
97597
97598
97598
97605
97605
97606
97606
97750
97755
97760
97761
97762
97802
97802
97803
97803
97804
98925
98925
98926
98926
98927
98927
98928
98928
98929
98929
98940
98940
98941
98941
98942
98942
99143
99144
99145
99148
99149
99150
99170
99170
99175
99183
99183
99185
99186
99195
99201
99201
99202
99202
99203
99203
99204
99204
99205
99205
99211
99211
99212
99212
99213
99213
99214
99214
99215
99215
99217
99218
99219
99220
99221
99222
99223
99231
99232
99233
99234
99235
99236
99238
99239
99241
99241
99242
99242
99243
99243
99244
99244
99245
99245
99251
99252
99253
99254
99255
99281
99282
99283
99284
99285
99291
99291
99292
99292
99304
99305
99306
99307
99308
99309
99310
99315
99316
99318
99324
99325
99326
99327
99328
99334
99335
99336
99337
99341
99342
99343
99344
99345
99347
99348
99349
99350
99354
99354
99355
99355
99356
99357
99406
99406
99407
99407
99460
99461
99461
99462
99463
99464
99465
99466
99467
99468
99469
99471
99472
99475
99476
99477
99478
99479
99480






California - MEDICARE CARRIER 01192 FSY2009 LOCALITY 18 FEE SCHEDULE PAGE: 46
PROCEDURE PAR NONPAR CHARGE
CODE/MOD FEE FEE LIMIT
PROCEDURE
CODE/MOD
PAR
FEE
NONPAR
FEE
CHARGE
LIMIT
PROCEDURE
CODE/MOD
PAR
FEE
NONPAR CHARGE
FEE LIMIT
97112 32.21 30.60 35.19
97113 38.90 36.96 42.50
99195
99201
85.85
41.62
81.56
39.54
93.79
45.47
# 99292
99304
113.29
86.64
107.63 123.77
82.31 94.66
97116 27.24 25.88 29.76 # 99201 25.28 24.02 27.62 99305 120.64 114.61 131.80
97124 24.92 23.67 27.22
97140 28.81 27.37 31.48
99202
# 99202
71.16
48.63
67.60
46.20
77.74
53.13
99306
99307
154.57
43.10
146.84 168.87
40.95 47.09
97150 19.71 18.72 21.53
97530 33.16 31.50 36.23
99203
# 99203
102.40
73.24
97.28
69.58
111.87
80.02
99308
99309
65.92
87.33
62.62 72.01
82.96 95.40
97532 26.53 25.20 28.98 99204 156.55 148.72 171.03 99310 128.55 122.12 140.44
97533 28.74 27.30 31.40
97535 33.09 31.44 36.16
# 99204
99205
122.53
196.95
116.40
187.10
133.86
215.17
99315
99316
62.87
81.92
59.73 68.69
77.82 89.49
97537 29.56 28.08 32.29
97542 30.00 28.50 32.78
# 99205
99211
159.40
21.69
151.43
20.61
174.14
23.70
99318
99324
90.39
58.81
85.87 98.75
55.87 64.25
97597 66.97 63.62 73.16
# 97597 34.71 32.97 37.92
# 99211
99212
9.32
42.07
8.85
39.97
10.18
45.97
99325
99326
85.17
139.64
80.91 93.05
132.66 152.56
97598 82.29 78.18 89.91 # 99212 24.83 23.59 27.13 99327 181.83 172.74 198.65
# 97598 46.07 43.77 50.34
97605 38.46 36.54 42.02
99213
# 99213
68.55
48.22
65.12
45.81
74.89
52.68
99328
99334
213.87
60.33
203.18 233.66
57.31 65.91
# 97605 27.86 26.47 30.44
97606 41.07 39.02 44.87
99214
# 99214
102.92
74.65
97.77
70.92
112.44
81.56
99335
99336
92.83
130.32
88.19 101.42
123.80 142.37
# 97606 30.47 28.95 33.29 99215 138.38 131.46 151.18 99337 186.78 177.44 204.06
97750 32.06 30.46 35.03
97755 36.23 34.42 39.58
# 99215
99217
106.13
72.33
100.82
68.71
115.94
79.02
99341
99342
58.81
85.17
55.87 64.25
80.91 93.05
97760 35.88 34.09 39.20
97761 31.61 30.03 34.53
99218
99219
67.47
111.52
64.10
105.94
73.72
121.83
99343
99344
136.33
178.39
129.51 148.94
169.47 194.89
97762 38.68 36.75 42.26
97802 32.12 30.51 35.09
99220
99221
156.53
96.47
148.70
91.65
171.01
105.40
99345
99347
214.31
57.26
203.59 234.13
54.40 62.56
# 97802 29.91 28.41 32.67 99222 131.71 125.12 143.89 99348 85.94 81.64 93.89
97803 28.23 26.82 30.84
# 97803 26.02 24.72 28.43
99223
99231
193.85
40.01
184.16
38.01
211.78
43.71
99349
99350
124.55
173.31
118.32 136.07
164.64 189.34
97804 14.09 13.39 15.40
98925 30.73 29.19 33.57
99232
99233
71.90
102.90
68.31
97.76
78.56
112.42
99354
# 99354
99.70
93.52
94.72 108.93
88.84 102.17
# 98925 23.22 22.06 25.37 99234 137.00 130.15 149.67 99355 98.53 93.60 107.64
98926 42.06 39.96 45.95
# 98926 34.11 32.40 37.26
99235 99236
179.50 222.89
170.53 211.75
196.11 243.51
# 99355 99356
92.34 90.09
87.72 100.88
85.59 98.43
98927 54.30 51.59 59.33
# 98927 44.58 42.35 48.70
99238 99239
72.04
104.29
68.44
99.08
78.71
113.94
99357 99406
90.82 14.16
86.28 99.22
13.45 15.47
98928 63.69 60.51 69.59
# 98928 52.64 50.01 57.51
99241
# 99241
54.64 35.64
51.91 33.86
59.70 38.94
# 99406 99407
12.39 27.02
11.77 13.54
25.67 29.52
98929 73.08 69.43 79.84 99242 100.93 95.88 110.26 # 99407 25.69 24.41 28.07
# 98929 61.15 58.09 66.80
98940 26.91 25.56 29.39
# 99242 99243
75.30
138.42
71.54
131.50
82.27
151.23
99460 99461
60.40 93.96
57.38 65.99
89.26 102.65
# 98940 22.49 21.37 24.58
98941 37.07 35.22 40.50
# 99243 99244
104.84 203.30
99.60
193.14
114.54
222.11
# 99461 99462
67.89 32.25
64.50 74.18
30.64 35.24
# 98941 32.65 31.02 35.67 # 99244 166.18 157.87 181.55 99463 81.47 77.40 89.01
98942 48.27 45.86 52.74
# 98942 43.85 41.66 47.91
99245
# 99245
249.25 207.28
236.79 196.92
272.31 226.46
99464 99465
75.73
156.34
71.94 82.73
148.52 170.80
99143 26.95 25.60 29.44
99144 25.42 24.15 27.77
99251 99252
52.25 81.46
49.64 77.39
57.09 89.00
99466 99467
248.66 124.07
236.23 271.66
117.87 135.55
99145 8.86 8.42 9.68
99148 67.38 64.01 73.61
99253 99254
123.76 178.99
117.57 170.04
135.21 195.55
99468 99469
926.42 406.91
880.10 1,012.12
386.56 444.54
99149 63.53 60.35 69.40 99255 218.14 207.23 238.31 99471 829.94 788.44 906.71
99150 18.10 17.20 19.78
99170 161.25 153.19 176.17
99281 99282
21.45 41.71
20.38 39.62
23.44 45.56
99472 99475
410.68 570.33
390.15 448.67
541.81 623.08
# 99170 102.49 97.37 111.98
99175 30.29 28.78 33.10
99283 99284
64.85
120.94
61.61
114.89
70.85
132.12
99476 99477
339.56 362.67
322.58 370.97
344.54 396.22
99183 214.00 203.30 233.80 99285 179.83 170.84 196.47 99478 148.38 140.96 162.10
# 99183 120.77 114.73 131.94
99185 68.32 64.90 74.64
99291
# 99291
277.99 226.74
264.09 215.40
303.70 247.71
99479 99480
129.87 124.94
123.38 141.89
118.69 136.49
99186 86.83 82.49 94.86 99292 123.90 117.71 135.37
CODES: 97112 - 99480
# - These amounts apply when the service is performed in a facility setting.
C - The payment for the technical component is capped at the OPPS amount.
Limiting charge applies to unassigned claims by non-participating providers. All CPT codes and modifiers are bolded.
All Current Procedural Terminology (CPT) codes and descriptors are copyrighted 2008 by the American Medical Association..
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